Recently, I interviewed Dr. Eric Balcavage, and we talked the connection between thyroid function and bile physiology. We discuss the functions of bile, its importance for thyroid hormone regulation, risks associated with excessive bile acid supplementation, factors affecting T3 levels, the significance of bilirubin levels, the importance of addressing underlying health issues, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am super excited to have a return guest, as we are going to have a chat about bile physiology and of course tie this into thyroid health. We have Dr. Eric Balcavage, who is the owner and founder of Rejuvagen, which is a functional medicine clinic in Concordville, PA. 

He is a nationally recognized speaker and educator on various health-related topics, including thyroid physiology, bile physiology, detoxification, oxidative stress, methylation, and chronic illness. Dr. Balcavage is a functional medicine practitioner and licensed chiropractor in PA. 

He is also the host of the Thyroid Answers podcast. The podcast focuses on answering the pressing questions those suffering with chronic hypothyroid symptoms can’t get answered elsewhere. You can find his educational Thyroid Thursday videos on both Instagram and YouTube. 

Dr. Balcavage has made it his mission to change the way medicine looks at hypothyroidism. He is the co-author of the book The Thyroid Debacle. The book is co-written by Dr. Kelly Halderman, and it addresses the problems with current allopathic and functional medicine approaches to hypothyroidism as well as the solution to restoring thyroid physiology. It is always a pleasure welcoming a fellow Dr. Eric. Thanks for joining us again on the podcast. 

Dr. Eric Balcavage: 

Thanks, Eric. Pleasure to be here.

Dr. Eric O: 

Really excited to talk about bile. Just want to have you jump into it. Before we start recording, you said that years ago, you did a three-day conference just focusing on bile physiology. 

Dr. Eric B: 

Yeah, the co-author of my book, Dr. Kelly Halderman, that’s why she is the co-author of the book. I was in the process of writing the book. Kelly reached out to me and said, “I need your help on a bile presentation for a supplement company called PHP, Professional Healthcare Products.” “Kelly, I don’t have time to help you with that. I have this book to write.” “I really need your help.” 

We had gotten together over a bile presentation I had done for Ben Lynch, when he used to have the Seeking Health conferences. I did a discussion about the significance of bile physiology as it relates to SIBO. Kelly was in that presentation and got more interested in bile physiology after hearing it. She got deep into the woods, which led to us working on that project. 

I said, “Listen, I will help you with the bile presentation, but then you have to help me work on the book.” Sometimes, you just need somebody else to help keep you motivated to get something done. Kelly needed some of that, and I needed some of that with the book. It all worked out really well. 

Dr. Eric O: 

Awesome. I would never have thought you could spend so much time talking about bile physiology.  

Dr. Eric B: 

I don’t think most people would have thought that. Three days of bile physiology… It was intense, and we got really nitty gritty. This was for clinicians, not the general population.

Bile physiology is so important to our overall health and being. We wind up taking gallbladders out and think, “Hey, nothing changes. Everything is just fantastic. This organ doesn’t need to be there. Let’s just get rid of it.” 

But I don’t think we really consider how important appropriate bile physiology is in the scheme of metabolism. We talk about thyroid hormone regulation and the significance of gut and GI function, which are critically important along with significant things like detoxification. Some of these things that create stress and inflammation out of the body appropriately. 

Dr. Eric O: 

Let’s talk more about the functions of bile, including the components, like bile acids and bile salts. 

Dr. Eric B: 

You have this organ called the liver. Liver makes this substance we call bile. It’s 95% water, which is really important because if you don’t drink a lot of water, dehydration could have an impact on your ability to make healthy, fluid bile.

The other pieces in there are cholesterol, which is a big piece of it; phospholipids; nutrients; toxins. What the liver is doing is making this substance that is almost like soap. That way, it can carry through these water-soluble substances into the stool, the urine, so we can excrete it. This soapy substance can also break down fats that are coming into the GI tract, so we can break it down and absorb those fats appropriately into the body, so we can use them. 

From a soap perspective, the bile is cleaning. It has direct and indirect effects on the bacteria coming into the GI tract to help break them down and not allow them to overgrow or colonize, especially small intestines. 

Bile has really significant impact on a lot of different processes in the body. It even plays a role in its ability to help regulate potentially the conversion of T4 to T3 in cells and tissues outside the GI tract because bile acids activate a receptor called TGR5 that increases that conversion. Too much bile acids in circulation could actually create more hyperthyroid signs and symptoms. It’s really important stuff.

We can break it down even more. You just tell me where you want to go. 

Dr. Eric O: 

I definitely want to talk more about bile and the thyroid. It’s also involved acts like an antimicrobial of sorts, but keeping bacteria in check, you would say, and other microbes in check. 

Dr. Eric B: 

When we eat food, we put the food into our mouth. It goes down into our stomach. Then the stomach produces acid. The role of the acid is to start breaking that food down into what we call chyme. It’s this predigested mix of stuff. As the chyme is moving into the small bowel, the duodenum, it starts to trigger the release of chemicals from the pancreas bicarbonate and digestive enzymes. It also can trigger the release of the substance that is coming from the liver and the gallbladder called bile. 

The liver makes bile with the help of thyroid hormone. That bile is excreted into the bile duct and then goes into something called the gallbladder. In the gallbladder, that bile gets concentrated from maybe a diluted soap to a more concentrated soap. 

When we get the signals from the stomach, “Hey, food is coming in here,” then the gallbladder squeezes some of those contents down into the tubes. The tubes from the gallbladder and the pancreas come together. It’s called the sphincter of Oddi. The pancreatic enzymes and bile acids enter into the upper part of the GI tract to start breaking down the foods into a more absorbable form.

But the bile acids and some of those digestive enzymes coming from the pancreas impact the bacteria that is coming from the food and our oral cavity, especially the bile. It’s a direct antimicrobial at the upper end of the GI tract. It can start breaking down the coating of the bacteria with these bile acids. 

In the upper part of the GI tract, bile acid is a direct antimicrobial. As the bile acids and all that food move down in the GI tract, the bile acids start to get resorbed in the GI tract. At the lower end, those resorbed bile acids are an indirect antimicrobial. 

As the bile acids are resorbed by the intestines, they’re actually initiating defense mechanisms at the lower end of the GI tract to make sure that bacteria doesn’t overgrow at the lower end of the small bowel as well. Plays a really important part on the bacterial levels in the bowel, especially in the small bowel/small intestine. That shouldn’t be the area that is as heavily compromised. 

I think when we talk about SIBO (small intestinal bacterial overgrowth) or SIMO (small intestinal microbial overgrowth), one of the big things I think is missed in people who are treated for chronic SIBO is they have lost the innate immune system of that small bowel, which is largely influenced by the amount of bile and the quality of the bile that is moving into the GI tract. If they don’t have good bile flow, then you can take an antimicrobial and knock the bacterial load down. 

Without the innate immune system that bile plays a big role in, there is a really good chance that the bacteria is going to start to grow back again because you’re constantly bringing in bacteria from your oral cavity. Bacteria and fungi off of your food are constantly coming off of the GI tract. If you lose the direct and the indirect drive from the innate immune system, you are probably going to have chronic infections or dysbiosis. 

Dr. Eric O: 

It’s way similar to hydrochloric acid. Obviously, a different location. HCl of course is also important for breaking down protein and minerals. It also has antimicrobial effects, just like bile acids. 

Dr. Eric B: 

They both have antimicrobial effects. They both do different things. The acid is really breaking down some of the heavy protein structure and getting that process started. The acidity of the chyme that is entering the duodenum plays a massive role in what is being released from the surrounding tissues. 

With acids, enzymes, bicarbonate, how much of this stuff needs to enter. If we lose HCl production, then we will have reduced acidity of the chyme. That will influence enzymatic input, bicarbonate. It is going to potentially impact the amount of bile that is entering into the GI tract. It all does start from the top.

What else is important is you need appropriate levels of T3 in the stomach to make stomach acid. You need appropriate levels of T3 at the liver and gallbladder. You definitely need appropriate levels of T3 at the liver to make appropriate bile and help regulate bile. You need appropriate levels of T3 in the GI tract to allow the sphincter muscle to open up to allow the bile and pancreatic enzymes into the GI tract. 

Thyroid hormone plays a critical role in stomach acid production, bile acid production, but also the release of both pancreatic enzymes and bile into the GI tract. Thyroid hormone is a part of all of these components to a healthy gut function. 

Dr. Eric O: 

You explain how thyroid hormone affects bile. Also, you mentioned how bile affects potentially conversion of T4 to T3, so there is that interplay there. You need healthy thyroid hormones to have healthy bile production, healthy conversion of T4 to T3, but maybe not too much bile. 

Maybe as far as supplementation- I was going to save the supplementation for later, but we can talk about it now. When you are taking something like an ox bile supplement, that is essentially bile in a capsule? 

Dr. Eric B: 

It sounds good on paper, right? If you don’t have good fat digestion, maybe you have a gallbladder issue, maybe you think that you should take bile. 

Now, when we eat food, and the liver is making bile, and the gallbladder is releasing bile into the GI tract, that bile is doing its job. Then it’s being resorbed. About 95% of the bile acids are resorbed back to the liver. You probably cycle those bile acids five, six, seven times through the process of trying to digest food. 

There are primary bile acids, which is new bile acids made by the liver. 

Then there are secondary bile acids, which are when those primary bile acids get into the lower part of the GI tract, into the large bowel. Bacteria, which is primarily in the large bowel, the colon, acts on those bile acids and convert the primary to secondary. We have both of these things recycling through the digestive process. 

A small percentage of those bile acids get out of the paddock bloodstream and into the overall bloodstream in the body. It’s those bile acids that play a role to some degree in metabolism because more bile acids in our overall circulation can then bind to receptors on cells and increase the conversion of T4 to T3. 

Taking ox bile can be great because that can help someone who is really struggling with fat digestion. But we have to be cautious, too, because this has happened to me. I was using ox bile on somebody, and they started having hyperthyroid symptoms. 

I wasn’t aware of this when the person mentioned it to me. This was maybe 10 or 15 years ago. The person said, “I think my hair is getting thinner. I am having these symptoms. I think it’s the ox bile.” I said, “I don’t think so.” I think it might have been one of the first times I used ox bile as a supplement. The person is having these negative symptoms. 

That is when I really realized I was giving them more bile acids than they needed, or more of those bile acids that I am providing them in that ox bile is getting into the bloodstream, and that is creating a hyperthyroid effect. As soon as we stopped the ox bile, the symptomology improved. We were back to normal.

Ox bile is a really common supplement that people use to help when there are bile issues, fat digestion issues. I think we have to be cautious with it and be aware that you could create some hyperthyroid symptoms in some of the tissues in response to using it, if more of it is getting out of that hepatic flow and getting into the bloodstream proper. 

Dr. Eric O: 

I see a lot of people with hyperthyroidism. I’ll admit, I’ve had hyperthyroid patients take bile salts. I guess the thing is, rarely do I give separate bile salts. I don’t know if I have seen the hyperthyroidism increase, or if it has, but I wasn’t aware of it. 

Usually, if I give it, it’s part of them taking digestive enzymes and butane HCl, like one of those common multis. It’s a small amount of ox bile compared to if you are giving a separate ox bile supplement that has who knows how much bile salts. Either way, something to be aware of. Even a small amount in some people might be problematic.

Dr. Eric B: 

Prior to that experience, I hadn’t used a lot of ox bile unless it was a part of a formula. One of my colleagues recommended the ox bile. This is what they use. “Why don’t you try it?” “All right, let me try it. Let me see what goes on.” 

It just so happened the first person I tried it with was a learning experience. The patient was fine. It was just one of those things where we both learned supplements are meant to be supplemental. Just because we think they’re all good doesn’t necessarily mean they always do what we want them to do, or there can’t be negative consequences from these things. It’s a good learning experience. 

For someone who is thinking they have gallbladder issues or fat malabsorption issues, be cautious. If you start to get some hyperthyroid signs or symptoms, and this person was starting to have some hair loss as a result of using it, let me try a formula that either doesn’t have ox bile directly in it or has a much smaller dose of ox bile. Some of these formulas have supportive ingredients. 

Dr. Eric O: 

You mentioned the importance of T3. If someone is having a conversion problem, normal T4, low T3, or both T3 and T4 are low, that could also affect not just bile production but a few other things that could be problematic. 

Dr. Eric B: 

This is a good topic because it presents a couple different talking points. When we think about thyroid hormone’s effect, the primary impact of thyroid hormone is via T3. A lot of tissues where most of the T3 is made, there are some tissues that only can use T3 from the bloodstream. There are other tissues, maybe 50% of the T3 that the cell is using is made within the cell. 

That is important because if we look at somebody’s thyroid panel, we see appropriate levels of T4 and low T3, the initial thought process might be, “I’ll give them T3 to offset what the body isn’t making.” They assume that if we give them more T3, it’s going to have the same effect that the cell would if it was making its own T4 into T3. Unfortunately, that’s just not the case.

Do you know Dr. Bianco? He just wrote a book on thyroid physiology. He has Deiodinase.org. He is an MD, smart guy. Really well known in the thyroid world from a medical standpoint. Dr. Bianco, we just talked about this the other day. He had a paper where he discussed how long the T3 that is coming from the bloodstream stays in the cell versus how long the T3 that is made in the cell stays in the cell. 

T3 that comes in from the bloodstream, I think that number is pretty short. Maybe a half hour or less. That T3 is in the cell. It comes in the cell and goes back out of the cell. 

But the T3 that is generated inside the cell may stay in that cell for closer to eight hours. That’s significant. It has a different impact when we convert T4 to T3. 

I say that because in an effort to think we’re optimizing somebody’s thyroid physiology or potentially try and make someone feel good, we see that reduced conversion of T4 to T3 and may say, “I’ll give them the T3, and that should fix the problem.” 

It may manipulate the blood levels, but it may not improve the function of the tissue. Why? Because that T3 may not get into the tissue as much as we think it will. We assume that the T3 in the blood correlates with what’s inside the cells and tissues, and that is not necessarily the case. It may not hang out there as long. 

When we see somebody who has reduced T4 to T3 conversion, and we see that they have fat malabsorption issues going on, then what we need to do is ask a better question, which is what is driving that reduced conversion of T4 to T3 and impacting the liver and gallbladder and sphincter of Oddi versus let me just throw more T3 into this system. 

In that situation, what should we do for the person who has fat malabsorption while we try to figure that out? That is where we can use these supplementation strategies. Make sure we are supporting the butane HCl if they have HCl issues. Add some of these good gallbladder support formulas that are available. There is a ton of them. We can support the fat metabolism while we try to address what is driving the adaptive decreased conversion of T4 to T3. My opinion. 

Dr. Eric O: 

When it comes to taking T3, would you say there is a difference between something like Cytomel, synthetic T3, compared to desiccated? I agree with you that you want to try to address the cause of the conversion problem. I am wondering if someone were to take desiccated thyroid over T3, if that would make a difference. 

Dr. Eric B: 

I don’t think so. If you think about what is really going on at the cell level, if the person has appropriate T4, and they have an inflammatory stress cell response going on that reduces the conversion of T4 to T3, and increasing the conversion of T4 to reverse T3, we might look at that and say, “Let me give them T3.” 

The same enzyme, deiodinase 3, which is supposed to be deactivating T4 to reverse T3, will still deactivate T3 to T2. We are just not seeing it. We might get a temporary change in some symptoms. Long-term, that T3 is not going to stay in the tissues very long. 

There are negative implications that come from taking that medication. We are now chasing the symptoms, so we want more and more. As you increase T3 intake, that starts to saturate some of the tissues in the brain and the pituitary gland. 

Now, there is a reduction in TSH. When you have a reduction in TSH, if you were getting some output from the thyroid gland, now you get less T4 production by the thyroid gland. Now, you have to make a decision. If I am increasing T3 to try to have an effect, is that then saturating the central axis, resulting in less T4 production by the gland? Now I either need to provide more T4, or I am going to need to provide more T4 and T3, based on what the provider is trying to do.

At the same time, we still may not have addressed what is creating that cell stress response. We haven’t addressed what is resulting in the reduced T4 to T3 conversion. We still may not improve function of the tissues that are struggling. We may see changes in the blood value, but the blood value doesn’t always correlate with what’s going on inside the various tissues. They can all self-regulate to some degree independently of what’s in the bloodstream. 

Dr. Eric O: 

Makes sense. If T3 is really low, let’s say if it was 1.5 on a blood test, you will still want to address the cause of the problem. Would you be in favor of giving T3? Would you say it depends on the person, the symptoms? 

Dr. Eric B: 

I would say it depends on the situation. I would think about why somebody might have low T3. There are three big considerations we have to take. Does the person have low T3 because the gland is not producing enough T4, or they are not taking enough T4? We have to evaluate that. 

Even though we have gotten away from running total T4, it doesn’t mean it doesn’t have value. It does. If you just have free T4, and it’s normal, high, or low, it still doesn’t tell us what the total are. Is the thyroid gland making enough thyroid hormone? You may not know. 

You could look at reverse T3 and say, “If I have high reverse T3, and I have a normal or high free T4, then maybe I am making enough T4 in the thyroid gland.” But we don’t know. I think it’s important to run it.

If the thyroid gland isn’t producing enough T4, and you’re not taking T4 medication, that could be one of the reasons why T3 and free T3 are low. We’ll know that by looking at a fuller thyroid panel. When we look at the totals, we get an idea. 

The other thing we can do is we should be able to take a look at the free T3 to free T4 ratio. If there is a global hypothyroid condition—the gland is not making enough, there is not enough T4 in the bloodstream—what we should see is a higher ratio of free T3 to free T4. Why? Because the cells are starving for thyroid hormone, and they want that converted into the usable form as quickly as they can get it.

In a true glandular hypothyroid condition, where there isn’t enough T4 and T3 in the system, and the T3 and free T3 are low, in that situation, we would look at that and say, “Ooh, this is a person who either needs iodine because they can’t make enough, or there is destruction of the gland, and they will need some support.” 

In that situation, would I recommend T4 and T3? I don’t prescribe, but I would say it is probably appropriate to give T4 first and see how they convert. 

The second reason somebody might have a lower T3 or free T3 is that they have some cell stress inflammatory mechanism going on. It is an adaptive change, where the body is not wanting to convert T4 to T3. That’s why it’s low. If that’s the case, then we’ll see that free T3 to free T4 ratio be low. 

In that situation, I wouldn’t recommend more T3 because if the body is trying not to convert T4 to T3, and we give them more T3 that the body probably didn’t want, is that helping them? You could say, “Sure, their signs and symptoms feel better.” But am I really helping them? That’s the question.

If your patient has a fever, should you give them aspirin or Tylenol to reduce the fever? Somebody would say, “Sure, it might make them feel better.” I might say, “Maybe not.” I’ll give them a cool compress and put them to bed because if they spike the fever, the fever isn’t the problem. It doesn’t make us feel good. But the fever’s job is to help in the healing process. People could argue both sides. In a situation like that, again, I would say no. 

The third reason that somebody might have reduced conversion of free T4 to free T3 and have a lower total of both is they are taking way too much T4 if they are taking medication. Too much T4 in circulation results in the ubiquination of deiodinase 2, so they turn down that T4 to T3 conversion in the peripheral tissues. Now they will have a lower T3 and free T3. In that situation, again, I wouldn’t recommend more T3. I would recommend that they reduce the T4 dose. 

The fourth issue that we have to take into consideration is that this could be a person who has a genetic polymorphism that does not convert T4 to T3 very well. If that is the case, they could have up to a 20% reduction in T4 to T3 conversion in the periphery. I would say it might be justified to do it. 

The fifth situation would be somebody who has had a thyroidectomy, had their gland damaged, radiation, whatever. The thyroid gland typically makes 5-10mcg per day. In that situation, if we are taking away the gland’s function, then we should mirror the production. That should be maybe somewhere between 5-10mcg that the thyroid gland would traditionally make. In that situation, I would say that’s a person who probably needs T3. 

When someone just has low T3 or free T3, I don’t like them to be on thyroid medication just to improve some of their symptoms because my goal with my clients is to figure out how to help that T4 to T3 conversion. It’s my feeling that in a lot of cases, giving T3 while creating short-term benefit, it is problematic in the long run to help normalize normal, homeostatic thyroid physiology. 

Dr. Eric O: 

Thanks for that explanation. I know we got off track with the bile metabolism. Thought it was important to bring that up. 

You did chat a little bit about this during our first conversation, especially testing the total T4 and not just relying on the free hormones, especially in the case of hypo. With hyperthyroidism, I still just test free T4 and free T3. But it does make sense with hypothyroidism when looking at the total output of thyroid hormone, not just to rely on the free hormones. 

Dr. Eric B: 

I don’t remember if we talked about it or not. When we look at the free hormones, we also have to consider is the free hormone low because of what’s going on with the binding globulins? The binding globulins, those transport proteins, can have an impact on how much is actually free. 

What influences those? Estrogen increases those binding globulins. Taking too much thyroid medication can potentially increase those binding globulins. There are things that influence the free values. If we are only looking at it in isolation, are we really seeing the full picture? I don’t think we are. I think we need to take a look at that. 

If somebody is hyperthyroid, we know. They have plenty of thyroid hormone available. That is usually not the issue. Sometimes, these things, depending on what your patient population is, it may change it. My patient population is primarily people who are struggling with hypothyroid symptoms or overmedicated or trying to find a magical dose. 

I do get some hyperthyroid-based patients. A lot of times, if I get them, I say, “Call Dr. Eric. This is what he does every day. Check with him. That might be the better match.” I do have patients who want to work with me who have hyperthyroidism, or they’ve had treatment for hyperthyroidism. Now they are on thyroid medication and back in the wheelhouse of how do I find that magic dose? 

In that situation, if you’re on the weight and age-appropriate dose for someone who doesn’t have a gland, and it’s not working, then you have what I talk about every day. There is still some type of cell stress response going on that is driving the immune inflammatory process. In those situations, once we get them close to what the thyroid gland would have made, then we have to get busy trying to find those stress responses.

Even though we both work in the thyroid world, what labs I think are important and what labs you think are important are really going to be centered around our patient population and what we deal with. 

Dr. Eric O: 

Makes perfect sense. You mentioned the effects of estrogen on the binding globulins. I also wanted to ask you about estrogen and its effect on bile metabolism as well. 

Dr. Eric B: 

Estrogen, especially excessive estrogen, can have an impact on thyroid hormone production and iodine intake into the thyroid gland. If you reduce iodine or thyroid hormone production, that can trigger problems downstream in thyroid hormone’s ability to regulate bile physiology. 

As we have increased estrogen, estrogen can influence the binding proteins. Because it can influence the binding proteins, that can reduce the amount of available T3 and T4 to get into the liver and the bile ducts and help with that regulation. 

Estrogen also impacts the sphincter of Oddi, which is the valve that needs to open into the duodenum to allow bile flow and pancreatic enzymes to move into the GI tract. If you have too much estrogen in the system, that can cause constriction of the sphincter of Oddi and keep it from opening up. That can lead to problems with reduced bile flow into the GI tract, so that can lead to fat malabsorption, gas, bloating, pressure, loose stools, permeability issues, and inflammation. It can also cause the bile to become thicker and lead to stone formation and gallbladder disease.

Unfortunately, we need estrogen. It’s really important. When we take a look at any of these systems, regardless of what somebody’s diagnosis is, we have to figure out how all these systems tie in. What is causing it? 

If we have fat malabsorption signs and symptoms or on a stool test, we might rush in there with some bile support. I often do because I understand how important it is. Let’s get you absorbing. Let’s get some support for fats and fat digestion. Then let’s start considering all the possibilities and probabilities that are resulting in reduced T4 to T3 conversion and what else might be impacting bile production and bile flow into the GI tract. Especially for women, estrogen issues could be top of the list. 

Dr. Eric O: 

If someone is taking an oral contraceptive, that also could potentially lead to, depending on what they are taking- 

Dr. Eric B: 

Depending on what’s in there for sure. 

Dr. Eric O: 

That could lead to gallstones by making the bile thick and sluggish. 

Dr. Eric B: 

Obviously, if someone has gallbladder disease, and it’s problematic, I get it. Maybe it has to come out. But if we just remove the gallbladder and have the ducts straight from the liver into the GI tract, and we still have a T4 to T3 conversion issue, or we still have an estrogen issue, did we really fix anything? 

We took the diseased tissue out. Now we have lost the concentration of the bile. It’s not as effective. It doesn’t have the same antimicrobial effect. It doesn’t have the same ability to break down those fats appropriately. It doesn’t have the same ability to absorb those free fatty acids across the membrane. It doesn’t have the same effect that this more concentrated bile might have. It would be like washing your dishes with a concentrated soap versus a really watered-down, diluted soap. It doesn’t have the same effect. 

I think that happens all the time. People say, “You have gallbladder disease. We will just take your gallbladder out, and you’re going to be good.” Well, the first question we should be asking is what are the issues that cause that gallbladder to become diseased to begin with? What was the patient’s estrogen level? What is their T4 to T3 conversion? Do they have dysbiosis? What are their lipids like? Is their cholesterol in the bloodstream high? Maybe that is having an effect on bile absorption. Are there things blocking the transport of bile flow in and out? What are the reasons that we have these issues and problems versus just take it out and you’re good? I think that happens too often. 

Dr. Eric O: 

Yeah, you want to try to fix the problem before it gets to that point. Years ago, my dad, when I was a teenager, he had to get his gallbladder removed, before I had the knowledge I had now. To me, it was a big deal because he was getting the surgery. They told him the same thing, no problem living without a gallbladder. He never even thought about addressing the cause. It might have been too late. It’s been a long time, so I don’t remember everything. By that time, even if he wanted to address the cause, he might have been too far gone. There are a lot of things people can do before getting to that point, is what you’re saying. 

Dr. Eric B: 

The other thing we have to consider for the patient is how would you even know if you have a bile issue or gallbladder issue or problem with the production? Gas, bloating, reflux, loose stools, greasy stools. You go to the bathroom, and there are stool stains on the side of the bowl. 

Some people talk about floating stools because maybe there is more fat in the stool. I have seen literature that says it’s more likely to be greasy stools. When you wipe, you will wipe a bunch of times. That is a greater indication there is higher fats in the stool. 

Even reflux. A lot of people are told they have too much stomach acid. You can get bile reflux if you are not breaking those fats down appropriately. If you have gas, bloating, pressure, loose stools, greasy stools, indigestion when you eat fats, there is a good indication that you’re starting to develop some challenges with your bile production. 

Dr. Eric O: 

Similar if someone has issues with fish oils. If they take fish oil supplements and are experiencing a lot of burping, that could be a sign, too. 

Dr. Eric B: 

I think it could be. I guess there’s some argument about the quality of all the oils that we’re buying. Are they oxidized or not? Someone gave me a bit of an in-depth education on the fats. To really make a high-quality fish oil derivative product is difficult because it’s easily oxidized in the processing. A lot of what may be creating issues—maybe it is liver, gallbladder issues, or maybe it’s the quality of the product we’re getting. Unfortunately, just looking at the back of the label may not give us the answer. 

How would you know? The average person wouldn’t know. If you are just buying fish oils or a fish oil derivative. If you are eating a lot of fats in the diet, and you are having more indigestion—burping, belching, looser stools—there is a good chance you are having some challenges. 

Dr. Eric O: 

How about high bilirubin? I wanted to talk to you about that and Gilbert’s. Some will say that Gilbert’s is not really a big deal. When I went through my Institute for Functional Medicine training, I don’t know if you’re familiar with Dr. Robert Roundtree. 

Dr. Eric B: 

I know the name. I don’t know him personally. 

Dr. Eric O: 

He was teaching the detox course. He had literature showing it was a big deal. You can’t just overlook something like Gilbert’s even though there is a genetic component. I wanted to get your thoughts on Gilbert’s and high bilirubin in general. 

Dr. Eric B: 

It is generally learned in school that as bilirubin levels are going up in the blood, we have problems with liver and gallbladder function. Do I think it’s important? I don’t care what the disorder is, if someone has it named. If your bilirubin is going up, you have a problem. 

There is a breakdown of liver and gallbladder problem. Someone might say AST or ALT are still good, so it’s not an issue. That’s nonsense. The vast majority of people, if they have elevated bilirubin, we should take notice regardless of what the diagnosis is. It shouldn’t be that high.

You could have a genetic predisposition to that being higher. If there is no signs or symptoms, and everything else looks good, maybe it’s not important. I think it’s really unusual that you see an elevated bilirubin, and there is not something going on. 

For the listener, bilirubin is a waste product. We break down red blood cells and the heme in red blood cells into something called biliverdin. That gets converted into something called bilirubin. Bilirubin is in your bile and should go out. 

If we are starting to see higher levels of bilirubin in the blood, that means it’s not getting through the liver and the gallbladder. It’s building up in the bloodstream, which is potentially problematic.

Just so you know, the reason your stool is brown is because of bilirubin. Your urine is yellow because of bilirubin. If someone says you have clay-colored stools, the reason they are clay-colored is you don’t have as much bilirubin getting into the stool to make it that darker black/brown color. It does give some of the pigmentation. 

If it’s elevated, it should be a warning sign to a clinician. I usually look at a range of .5-.8. If it’s in that range, we’re probably good. Then again, we also have to take a look at red blood cells. Am I anemic at .8? If I’m anemic and .8, maybe that’s too high, versus if I’m not anemic. 

The other issue is low bilirubin, which gets no attention. If you look at a lab report, as long as it’s less than 1.2, you’re good. I don’t think that’s the case either. 

Low bilirubin, does that mean you have a gallbladder problem? I don’t know if that means you have a liver problem or a gallbladder problem, but it probably means you have an oxidative stress problem. Bilirubin can be converted back to biliverdin, and biliverdin is a potent antioxidant. The body can help deal with the oxidative stress in the body by instead of excreting the bilirubin, it would convert it back into biliverdin so it can have an antioxidant. 

We need to look at the highs and lows. Even when it’s normal, we have to interpret it based on what our other values are.

To summarize that, regardless of what your diagnosis is, if you start to see your bilirubin creeping up above .8, you have to start to look at the rest of the labs: ALT, AST, GGT. You can look at the AST:ALT ratio. If that is elevated, then we have to start considering that something is already developing fatty liver disease. If they are starting to develop fatty liver disease, is that going to affect bile function and physiology? Absolutely. 

What does that mean about thyroid physiology? It means you probably don’t have great T4 to T3 conversion supporting the liver. Then I can’t burn those fats as a fuel. I can’t burn the glucose as a fuel. 

Definitely when you think about that bilirubin number, regardless of the diagnosis, if it’s creeping up above .8, somebody should take notice. If it’s below .5, we should take notice and say, “What the heck is going on here with the oxidative stress or this liver/gallbladder physiology?” 

Dr. Eric O:

It’s interesting. I admit I’m guilty of not paying attention to lower bilirubin. It’s not red flagged if it’s low. I know you can’t just rely on labs. I look at the high side and the low side. I did not know if it gets too low that there could be potentially a oxidative stress problem, so that’s good to know. 

Dr. Eric B: 

We have to look at the red blood cell population. If they have an anemia pattern, that could be why it’s low. There are not as much red blood cells breaking down. They are hanging around longer because you don’t make as many. 

This goes back to interpretation, which hopefully we do better than sometimes in allopathic medicine, where they are just looking for H and L. In functional medicine, we should be interpreting the labs and saying what story do these labs tell us about my client? How does that match with their signs and symptoms? That way, we can be more specific with a treatment strategy. 

Dr. Eric O: 

Makes sense. For current gallstones, there are all these remedies out there. As far as supplements, not necessarily for gallstones specifically, but supporting bile metabolism, not just bile salts, but there are other supplements like things with beets for example to help with bile metabolism. If someone has an existing gallstone, if it’s not serious, if it’s not blocking a bile duct, is there anything they could do as far as shrinking the stone or breaking the stone? Are those things that are out there not really breaking gallstones? 

Dr. Eric B: 

There is a lot of things that are out there for gallbladder cleanses and hydrogen peroxide that people drink to try and break up the stones. I don’t try to do that necessarily. I don’t have people do them. 

I think the chances of things going well, maybe they’re good, maybe not. I have had patients in the past who did these things and wound up with emergency gallbladder removal. What happened with whatever they were doing, using some fats and hydrogen peroxide, whatever their cleanse was, actually created more stress and expansion and inflammation. 

Some of these strategies are trying to force the flow. If there are things restricting flow, and you are creating this real need to force the emptying of a gallbladder, you’re going to be in trouble. I don’t typically recommend those strategies. 

I think the better model here is a number of different supplements out on the market that are either designed to help support better bile production or to support healthier bile flow. Lots of companies have those things out there. 

I would suggest that whomever thinks they have issues should work with your functional medicine practitioner to guide you in the right direction as to what might be the best strategy in your situation. That is step one. Step two is what is causing this problem to begin with? 

Dr. Eric O: 

I’m glad you brought that up. I wanted to get your perspective. I don’t recommend anything to break up gallstones. Like you said, there is risks as well of doing that. Just because it’s a supplement you’re taking doesn’t mean there is no risk. Like you said, you could end up in the ER. Not to say it will happen most of the time, but even if it’s 10% of the time, or whatever percentage, that’s a risk. 

Dr. Eric B: 

I read a paper a while ago, and they started breaking down those gallstones. It was interesting. In this one paper I read, what they were finding was a lot of bacteria at the center of those stones. What was the underlying cause? 

It is one of those things that we have to consider. Is bacteria getting somewhere in that area of the body, maybe getting up the duct into the gallbladder? Is the stone really the problem in some of these situations? Or again, is that the body’s adaptive response? Hey, we have this bacterial. Let’s surround it and encase it versus obviously there could be a problem, especially if they create a congestion issue. 

The body is pretty cool. A lot of the things we think are the problem are the body’s adaptation to try to protect itself. In a situation like that, if we actually knew then, we don’t typically have the ability to pull a gallstone and throw it under a microscope at home and see what is at the center of it. That is one of the things we have to consider. What is going on even from a gallbladder function or dysfunction related to organisms? It can be. 

Dr. Eric O: 

The last thing I wanted to ask you is life after gallbladder surgery. If someone sees you and has already had their gallbladder removed, but they are still having the underlying bile metabolism problems, does that person necessarily need to be on support permanently since they don’t have a gallbladder? Obviously, you want to address the cause of the problem. Once it’s addressed, can they be off of bile support supplements? Is that something you think they need to take continuously? 

Dr. Eric B: 

I tend to lean toward people using something longer-term. Again, I would look at labs and signs and symptoms. We can look at high cholesterol or high triglycerides in the stool. If we see higher fats in the stool, it’s a good indication that this is maybe a person who is not absorbing their fats very well. In that situation, we might want to have them on it.

If it looks like they are a person, especially if you look at their labs, their triglycerides and VLDL are relatively low, and even LDL is relatively low, we might consider they are not doing a great job of absorbing triglycerides into the system. 

As you well know, the difference between VLDL and LDL and HGL is the amount of triglycerides and ratio to cholesterol that is on those lipid proteins. If their triglycerides are low, and you ask them what they are eating, if that’s what they are eating and their triglycerides is low and VLDL is low, this person will probably need some gallbladder support.

Triglycerides is another one of those things where the lab range says less than 145 or whatever. But whether it’s high or low, it’s telling us a story. If I have someone who has low triglycerides and low VLDL but has low glucose issues and other issues going on, there is a good chance that they have fat malabsorption going on. Especially if they have chronic mineral deficiencies, you really have to look that way. 

I wouldn’t say it’s a blanket statement; everyone has to have it. I would lean more toward that people are going to need some support because they have lost that bile concentrating ability when they have lost their gallbladder. 

Dr. Eric O: 

With triglycerides, what do you consider too low? Less than 50? 

Dr. Eric B: 

Yeah, probably under 50. But it would depend on what their diet was like. That would be a flag for me. If I saw it under 50, I’d be like, “What’s going on here? Tell me what you’re eating.” Based on that, let me look at the VLDL. That’s low, too. “Tell me about your stools. Tell me about your gas, bloating, pressure.” If the picture sounds right, put them on it. 

If you do a stool test, and you can see elevated steatocrit, or you do Vibrant’s Gut Zoomer test and see triglycerides and cholesterol elevated, they are getting some support. 

Dr. Eric O: 

Makes sense. This was amazing. Is there anything else that I didn’t ask you that I should have asked you with relation to bile physiology? Again, you spent three days, so I’m sure there is another few hours we could go on. Anything really urgent? 

Dr. Eric B: 

Bile acids also play a critical role, not just in the immune system of the GI tract, but the permeability of the GI tract. They help to manage those tight junctions. For the person who has maybe been told multiple times, “Hey, you have chronic leaky gut,” especially if you have had multiple episodes of chronic dysbiosis, and nobody has looked at bile physiology for you, that really should be considered because the bile acid resorption helps maintain the tight junctions of the GI tract. 

It is not just an issue of fat digestion; it is not just an issue of antimicrobial capacity at the top end. If you don’t have healthy bile physiology, it can lead to the chronic leaky gut. Most of us are aware it can lead to chronic inflammation, food reactivity, food intolerances, even systemic infections from what’s going on in the GI tract.

Dr. Eric O: 

That’s important. Leaky gut is pretty prominent. 

Dr. Eric B: 

Yeah, could be. 

Dr. Eric O: 

All right. This was amazing. Thank you so much for getting together again to discuss bile physiology. Where can people find out more about you, Dr. Eric? 

Dr. Eric B: 

The Thyroid Answers podcast, which you’ve been a guest on. We’ll get you back again. Anywhere you can get podcasts.

Instagram and Facebook, I’m on, too. We do our Thyroid Thursday videos there. I answer a lot of questions on there. The book is The Thyroid Debacle. 

My website is RejuvagenCenter.com. They can reach out there. I do discovery calls. Every day, I do at least two over my lunch break to help answer questions for people who are not quite sure where to go or what to do or are confused about their health in some way or their thyroid physiology. I use that time along with the other platforms to help give people the answers that they are looking for that they maybe aren’t getting elsewhere. 

Dr. Eric O: 

Of course. Thank you so much, Eric. This was great. Appreciate you taking the time to dive deep into bile metabolism. 

Dr. Eric B: 

I appreciate the opportunity, Eric. 

Recently, I interviewed Divya Gupta, and we talked her health struggles, why we need a holistic approach to health, symptoms of gallbladder problems, the impact of bile metabolism on thyroid function, the connection between the thyroid and the gallbladder, what you need to know about testing, how you can support liver function and bile metabolism, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am very excited to be speaking with Divya Gupta, who is a board-certified nutritionist and restorative wellness practitioner, specializing in gut health. Departed from her 15 years in corporate America to establish Divya Nutrition and Wellness. Faced with personal challenges such as gallbladder removal and a Hashimoto’s diagnosis, she became a wellness advocate, guiding ambitious professionals on a personalized journey to reclaim their health and live life on their terms. Her expertise reflects a departure from conventional approaches, emphasizing a holistic approach to wellbeing. 

Thank you so much for joining us, Divya. I am very excited to chat about the gallbladder and bile metabolism. 

Divya Gupta: 

Thank you so much, Dr. Eric, for having me. I am looking forward to our conversation and collaboration. 

Dr. Eric: 

Same here. I gave a little sneak preview about your background in that you had your gallbladder removed. I am guessing that’s how your journey started. Maybe you can go into some more detail. Not everybody who gets their gallbladder removed decides to help people with gallbladder issues. What made you undergo that transition? 

Divya: 

I think a lot of us in the health space either have dealt with our own health issues or have seen someone really close to us, someone we love, go through those challenges. In my case, it was both. 

If I take a step back, I am an Indian immigrant. This year will mark my 20th year in the United States. Gosh, I have been here for two decades. I came here on a very stereotypical path. I did my computer science engineering back home and came here for my master’s. I went to an Ivy League school. Subsequently, the American Dream, I got into corporate America. I was living in NYC for over eight years, working for a top consulting firm. 

My health challenges started while I was still in India. I was in my final year of engineering when I started getting gallbladder attacks, which I didn’t know at that point they were gallbladder attacks. 

Dr. Eric, I don’t remember a lot of things about when I was 20. It was two decades ago, or more. I don’t remember a lot, but I can still close my eyes and picture myself back in my bedroom, up at night, with pain, like 2am-3am, pacing the room. It kept happening every night. I would just chalk it up to, “Oh, I ate something funny earlier. Maybe it’s gas.” It was the abdomen area in general. 

It kept on happening for a few nights. The intensity of the pain would go up until I finally told my parents. They said, “Wake us up next time you’re in pain.” It happened again. I woke them up. This went on for a few weeks. Doctor visits, trying different medication, but nothing really worked.

Until one fine day, I was in excruciating pain. It was horrendous. Let’s go to the hospital at night. We had the radiologist there, who finally did an ultrasound and said, “You have gallstones.” In one sense, I was relieved. At least I knew what it was. On the other hand, I had no idea what the gallbladder did at that point. I had no clue what its function was.

The next step was seeing an endocrinologist. The option given to me was “We don’t need our gallbladder; we can take it out.” Perhaps that was the best decision for me at that point and for my life. We decided to schedule that surgery although I was knee deep into my exams and preparing for my GREs to come to the U.S. I had it scheduled, but life had other plans. 

One night, the pain was so intense. I was throwing up. I have been through childbirth now. I would still take childbirth over that pain any day. I don’t wish that upon anybody. It was horrendous. Nothing would help. You just have to keep pacing the room. The stomach would spasm as if there was some muscle twisting inside. My gallbladder was taken out. It helped with the pain. Everything was good. I felt good. Life went on as planned.

Now, I came to the U.S, as I said. I was put into a new environment. Mores stress, living away from my parents for the first time in a new country. Food, I was a vegetarian back then, eating a lot of higher carbs, eating out a lot. The portion sizes were huge, too. I slowly got used to accommodating them.

A few years down the road, when I was 24/25, I got a Hashimoto’s diagnosis. Knowing what we know now, that it’s connected, but back then, nobody looked into making that connection. I was given Synthroid by the doctor. I think she spent 10 minutes with me and gave me two pamphlets. “This is Graves’ and Hashimoto’s. You have Hashimoto’s. Here’s some Synthroid.” I got my dosage and was on my way.

For a lot of people, I know medication takes a while. For me, it really worked. It actually helped me feel better. I didn’t realize I was tired at the time. At 25, I needed a nap in the middle of the day if I could get it, or a pick-me-up for sure, and a lot of muscle aches. It really helped with a lot of those symptoms.

You trust your doctors. That is the best decision. That is what I need to do. For me, what connected the dots that I needed to look into more and lit the fire was my mom was going through a similar journey. She had her gallbladder removed a few years before mine, but she never had any pain. That’s why we didn’t make the connection when I was having such active pain. Then she had a Hashimoto’s diagnosis. Around my diagnosis of Hashimoto’s, she got rheumatoid arthritis. 

As if I was watching a movie, if I don’t make any changes, I’m following her path. That’s something I don’t want to follow her path on. I could see her life quality degrade. Her being in so much pain and the steroids she had to take to manage. That is when I decided I need to take things into my own hands. I was dismissed by a few doctors when I would go in there for muscle aches. They said, “You’re too young. It’s in your head.” 

At that point, when you’re so young and naïve and don’t know how to advocate for yourself, I thought maybe it was in my head. My muscles would hurt. What can I do? What can I take in control? That is when I started looking into nutrition, diet, and lifestyle. 

This is now 15-16 years ago. There wasn’t as much information available until you went looking for it. I started looking. I picked up a few health books. I changed my diet. I took out gluten and dairy for a week. That is when I realized I had bloating. We normalize feeling a certain way in our body. Until I took those food groups out, I felt lighter and had more energy. That is how I knew this thing worked.

I started making changes to my diet and lifestyle. I learned everything I could. That is where my love and passion for health and wellness started. I would have never thought in a million years that I would do a 180-degree and switch careers. I worked in a top consulting firm. I moved to Silicon Valley. I was working in tech start-ups. I knew there was more. I wanted to help people not go through the journey I did of decades of trying to figure it out on my own. Nobody was talking about it. 

That’s when I decided to go back to school and get my nutrition degree, get board-certified, get into restorative wellness, get certified in gut health as well. It’s been a few years where I decided to focus on my practice full-time and help as many people as I can, so they don’t have to go through their parents’ journeys or go through what I did and spend decades figuring out what’s going on. They can start really living life on their terms because that’s my goal. No matter how long I live, I want to be able to do the things I love and not be reliant on medications for the rest of my life. 

Dr. Eric: 

Thank you so much for sharing that story. Essentially, you had your gallbladder removed. Years later, you developed Hashimoto’s thyroiditis. You also suggested that the problem with the gallbladder might have been a potential cause for Hashimoto’s and also potentially others as well. Can you talk a little bit about the connection? Most listening to this definitely have that question since most people listening to this have a thyroid or autoimmune thyroid condition but maybe didn’t think about that connection. 

Divya: 

Great question. Let’s take a step back. When we talk about a thyroid, for it to function properly, we need at least five of these organs to work properly and synergistically: your brain, thyroid, liver, gut, and adrenals. 

To answer your question, we will take a deeper dive into the liver, gallbladder, and thyroid connection. Liver, as we know, is one of our most important organs. It does so much for us. It produces cholesterol. It produces bile, which is made of cholesterol and a lot of other raw materials. It processes Vitamin D. It detoxifies our blood. It gets nutrients to where they need to go. And so much more. 

All these organs, the thyroid sits in the base of the neck. Your liver, gallbladder, and abdomen, how are these connected? When the bile, which is produced by the liver, is stored in the gallbladder. Now your gallbladder is  a pear-shaped organ right below your liver. The bile plays a huge role in breaking down the fat in your fatty meal to be able to digest the nutrients from those meals. It has a few more functions as well.

The liver produces that and stores it in the gallbladder. That really helps for it to get concentrated. When we do eat a fatty meal, we have the adequate amount of bile present and the right quantity, so when we are eating a fatty meal, it can squeeze out the bile to break it down. 

One of the important functions of the liver I forgot to mention is when our inactive thyroid hormone is converted to the active form. T4 gets converted to T3. All your listeners know that thyroid plays such a critical role in every function of our body, from digestion to immune system to our energy to our metabolism, etc. 

Now, we have around 50 trillion cells, at least. Each of these cells have a receptor for our thyroid hormone. Our gallbladder as well has a receptor for the thyroid hormone. Since thyroid really influences energy, people with Hashimoto’s may feel fatigue and tired. That was definitely one of my symptoms, feeling tired. 

When we eat a fatty meal, our gallbladder has to contract to squeeze out the bile. If you are low on thyroid hormone, and again, you could be clinical. It doesn’t have to be outside of the range; you could be on either end, higher or lower. You don’t have enough of the active hormone, or the conversion isn’t taking place. Your gallbladder gets a little lazy or not efficiently squeezing it out. What that does is it backs up the bile, so it accumulates and stagnates. Then it could form gallstones as well. 

There is such a symbiotic relationship between these organs. You could have a thyroid issue, which causes a liver issue and gallbladder issue. And vice versa. When your thyroid hormone is low, it can also have an impact on your cholesterol production, which is a raw material for bile. Your bile is made up of bile salt, bile acid, bilirubin, phospholipid, and water. It can have an impact on that. 

A lot of Hashimoto’s and autoimmune condition patients also have low motility as an issue. You could have constipation as well. That could back up your system. The toxins go up, and it could be signaling to your liver, “Hey, we have too much bile.” Bile needs to get excreted out, and it gets reabsorbed into our liver. That could cause a miscommunication dysfunction as well. 

In my case, having the gallbladder was just the tip of the iceberg. There was so much more underneath it that needed to be uncovered of why the dysfunction happened. Yes, we can function without a gallbladder. I am still alive. But it does provide a function of concentrating the bile, so it’s present when we need it, so we can absorb the nutrients. I think that’s the question to ask. When the gallbladder is dysregulated, what else is going on underneath the hood? 

Dr. Eric: 

I think it’s important what you said. It’s not a gallbladder problem; it’s what’s underlying. Similar to when someone has an autoimmune thyroid condition, and they remove the thyroid, which there is a time and place for that, just as there is a time and place for gallbladder surgery, which we can talk about later. 

Again, if someone has Graves’ or Hashimoto’s, and they remove the thyroid, which is more common in Graves’ but sometimes happens in Hashimoto’s, too, they are not addressing the immune system problem. 

The problem with the gallbladder is you have a problem with the bile metabolism. It’s not the gallbladder itself. 

I also like what you said that it could affect the thyroid, and thyroid could affect gallbladder. You’re right. Thyroid hormone affects every cell/tissue in the body. If you don’t have adequate thyroid hormone levels, that could affect the bile and lead to bile that is more sluggish. If you have issues with liver and bile metabolism, that in turn could affect gallbladder.

I don’t know if you would have the answer to this. When you had your Hashimoto’s diagnosis, was it five years after the gallbladder removal? 

Divya: 

Yeah, 4-5 years between that period. 

Dr. Eric: 

Maybe the underlying bile metabolism issue was a factor in the development of Hashimoto’s. But also with Hashimoto’s, it is underlying for many years. For all you know, you might have had the Hashimoto’s prior to the gallbladder problem, but it wasn’t diagnosed until five years later. You don’t know what exactly causes what. 

Either way, it’s all about addressing the root causes. If anybody has Hashimoto’s, you want to find and remove the triggers and heal the gut. If someone has a gallbladder problem, you want to try to address any underlying imbalances in the liver, the bile metabolism. I appreciate you sharing that.

I jumped the gun a little bit. I probably should have asked first: What are some of the more common symptoms? You did mention some of your symptoms, like nausea, vomiting, and pain. What should someone look for when they are having a gallbladder problem or again a bile metabolism problem? 

Divya: 

Before I answer that, I was looking into some stats. In the U.S., there are 600,000 gallbladder removal surgeries performed every year. 20-25 million people have a gallbladder issue or will have one. I went down the rabbit hole. I was curious about what happens in India. 6% of India’s populations, which is 85 million. It’s a problem that is happening a lot more. People are not figuring out; they find out later.

When I was having nausea and pain, while I was still having the attacks. I don’t remember. Maybe I was having symptoms that I never paid attention to. If people are having gallbladder issues, some symptoms to look out for are the physical symptoms of pain in your right abdomen, right under your liver. If you are feeling the right side of your rib. Sometimes, the pain could also go to your right shoulder. A lot of people feel pain in their right shoulder because they are connected.

If you are getting bloated, especially after eating a fatty meal. Bloating can happen for a lot of reasons. You can have food sensitivities, especially if there is an underlying autoimmune condition, like a leaky gut or potentially SIBO. Especially after eating a fatty meal, you feel bloated.

You could have stomach distension, or you’re burping a lot more. 

Bile contributes to the dark brown color of stool. If you start noticing clay-colored stool or darker urine, those are some signs to pay attention that could indicate that there is some gallbladder or liver dysfunction going on. 

Dr. Eric: 

When it comes to foods, is it just unhealthy, greasy foods? Do people with gallbladder issues also have issues with coconut oil, avocadoes, other healthier types of fats? 

Divya: 

In terms of what are causing these gallbladder issues, there could be several. One is our SAD, Standard American Diet, which is higher in processed foods and trans fats, and low in fiber. What we have seen arise in our metabolic diseases: obesity and diabetes can have an impact on cholesterol production. So much more also could be causing gallbladder issues.

Genetics definitely play a role. You and I both know that we have the genes, but what triggers it is our environment and lifestyle.

We also talked about how thyroid could be one of the reasons as well.

In terms of the food perspective, it’s not the fat that is causing the issue. It’s the bile. It’s more of the trans fats. People should still consume high quality fats from avocadoes and olive oil. But focus on high fiber diet. 

Bile also helps to get rid of hormones like estrogen by binding to fibers. Focusing on a high fiber diet with more fruits and vegetables, lean protein, and essential fats. 

Coconut oil. MCT could be easier for your body to break down because they are medium chain and not harder to break down. Also making sure you stay hydrated as well. With anything, you want to focus on quality. 

When we talk about bile’s role, one thing we are talking about is it helps in digestion and breaking down fats so that the lipids can really do their magic.

The other role that the bile plays is getting rid of toxins and extra estrogen. Helping us uptake fat soluble vitamins: A, D, E, and K. How many of us are on Vitamin D supplements? The value isn’t going up because if you don’t have the bile to help synthesize and absorb these minerals, you can take all the supplements, but they don’t work. 

A lot of people will chalk it up to old age. When Vitamin A is going down, and your eyesight is getting weak, or your Vitamin K is low, which helps with blood clotting, or Vitamin E, which is one of our powerful antioxidants in our body, bile’s role is not just to digest fat but also with uptake of these fat soluble vitamins and excrete the estrogen and hormones that we don’t need. 

One of the analogies I like to use is a soap dispenser. When we are trying to get grease out of our dishes, we want soap, and we want it in the right quantity and thickness, so it can actually take the grease out. Well, that is why bile is so critical because it really concentrates, so when we do eat a fatty food, it’s able to break it down and absorb it. 

The soap dispenser, we need to push it to get the right amount out. If your gallbladder is not able to squeeze it out, your bile is there, but it’s not squeezed out. It could also impact things, causing gallstones. I know I covered a lot in there. 

Dr. Eric: 

Like you said, you covered a lot of different things. The fat soluble vitamins was interesting. If someone is running a Vitamin D test, and maybe they are taking 10,000 IUs of Vitamin D, because they had a deficiency, and then they retest, expecting the levels to be healthy, and it’s still on the lower side. Maybe it’s within range but less than optimal. A lot of people would overlook that maybe you’re just not breaking down the fats. Maybe you do have something underlying. 

With Vitamin D, you could easily test. It’s not as easy to test some of the other fat soluble vitamins. You might have deficiencies in the others and not know. I appreciate you bringing that up. 

Divya: 

In terms of tests, there aren’t that many exact tests correlating to bile. We can take a look at our liver tests. Everyone has easy access through their primary doctor or annual physical, your AST, your ALT. Your bilirubin could be a big indicator. Also, GGD and alkaline phosphate. Those are some tests that are available and can really indicate if your liver is being dysfunctional because they are interconnected. Does your liver need help? 

A lot of people with Hashimoto’s will have suddenly higher cholesterol. “I am not eating high cholesterol foods. Why are my LDL going up and overall cholesterol going up?” Your thyroid has a direct impact on your liver and the production of cholesterol. That could be raising your cholesterol levels. 

Dr. Eric: 

Yeah, that is a common finding. We see total cholesterol and LDL elevated. Estrogen metabolism, you also said that’s important. Having healthy bile metabolism is important for clearing out estrogen. 

I don’t know if you do any dried urine testing/Dutch testing, but Dutch testing looks at the estrogen metabolites. I guess what I’m asking you is if someone has a problem with estrogen metabolism, clearing out the estrogens, then if I’m understanding you correctly, it could be related to bile as well? 

Divya: 

In a few months, I will have the capability and training to do the Dutch test in my practice. I’m always learning in this space. There is always so much to learn. 

As we have a gallbladder, if I have my anatomy, has a receptor for thyroid, it also has a receptor for your estrogen and progesterone and other sex hormones. With estrogen, there are all of the metabolites, which our body needs to get rid of. If you are recycling that, if bile is not able to clear it, we could see that being an issue as well. 

I think that’s why women are more prone to gallbladder issues than men comparatively. With the recent estrogen dominance, a lot of men are seeing issues with clearing bile and gallbladder issues as well. There is a correlation with your sex hormones and bile. It’s all interconnected. 

Our body is so beautiful. Everything is interconnected as we were talking about: your thyroid, liver, gallbladder, and gut. They are also multifaceted. They don’t just perform one function; they perform so many functions. That is the beauty of the body. That is what fascinates me. There is so much more to understand of what’s going on and to uncover when you are having an issue. 

I think that’s why working with the right practitioner who can actually help you uncover the root cause and not just look at the tip of the iceberg. For example, we have a gallbladder, let’s just get rid of it. Instead, what’s going on underneath it? Let’s figure out because everything is interconnected. Nothing works in isolation. 

Dr. Eric: 

Well said. I definitely agree. 

Also, I should bring up fish oil. A lot of people have issues with fish oils, too. They will get the burping. Sometimes taking an enteric-coated fish oil might help. In most cases, would you say that is also related to problems breaking down fat and potentially bile metabolism issues? 

Divya: 

Absolutely. Omega-3s are also fats that need bile’s help to absorb. That’s why we go back to the symptom. If you’re getting burping, if you have gallbladder issues, you might be experiencing burping as well. It helps with getting rid of hormones. I think a lot of people don’t realize that hormones are made of fat. That’s why bile is so crucial for even binding to those hormones, so they can be excreted out through the fecal matter. 

Dr. Eric: 

Getting back to testing. Bilirubin, you don’t hear people talking too much about bilirubin. If it’s elevated, that also can mean a problem with bile metabolism? 

Divya: 

Bilirubin is breakdown of your red blood cells. If in the liver it’s elevated, that could indicate dysfunction in the liver. You do need to look at it across all the other liver tests. Our bile also consists of bilirubin. That can be one indicator or sign to look out for to dig into it a bit deeper as to what could be happening. 

Dr. Eric: 

It’s also important to mention that for those who are listening to this who have hyperthyroidism, sometimes you get strange findings. You might get elevated bilirubin, and you might think that’s a problem with bilirubin, but it could be related to hyperthyroidism, not bile metabolism. 

There is also Gilbert’s syndrome, too, which I’m sure you’re familiar with. I am not sure how much experience you have with it. If someone has elevated bilirubin with Gilbert’s, I imagine you can’t get it normal permanently. You might have to offer support continuously in that case. 

Divya: 

I don’t have too much experience with that. I’ll let your expertise speak to it. 

Dr. Eric: 

Let me ask you a different question, which leads into treatments for gallbladder. The question I have, which will be after you talk about treatments, is what you do. You don’t have a gallbladder. 

Before we dive into that, what would you recommend for someone who I guess does have a gallbladder but wants to save their gallbladder? They don’t want to get gallbladder surgery, but they might have some of the symptoms you mentioned earlier. What are some things they can do if they have an existing gallbladder problem or bile metabolism problem? Or maybe they don’t, but they want to prevent one. 

Divya: 

I love this. It’s never one approach or one thing that’s going to solve it all. You really want to look at it from your diet, your lifestyle, and some targeted supplements that could help.

When it comes to diet, really focusing on high quality, high fiber, fruits and vegetables. Getting processed foods out of the diet. We haven’t talked about the gut, but we want the good microbiome, and it loves fiber. 

Also, focusing on healthy fats. 

Third, I would say supporting your liver. Incorporating liver-loving foods, like liver loves bitter. Adding arugula, endive. There is an Indian vegetable called bitter gourd. I don’t know if you’ve heard of it. It’s available in a lot of Asian markets. It’s really bitter. We love it in my house. Adding some bitter vegetables. Even grapefruit, artichokes, cruciferous vegetables. The allium family, onion and garlic. All those vegetables are really supportive for liver, so adding those to your diet.

Along with that, I love herbs and spices. Turmeric, cinnamon, ginger are also very supportive. Incorporating those. 

One of the practices I have incorporated over the years that has become habit is starting your day with hot water and lemon, or apple cider vinegar (ACV). It really helps to support liver health for detoxification. Those are from the nutrition end. 

If you have a gallbladder and liver and want to keep them, how can we decrease the toxic load that our liver has to process? We know one of the functions of the liver is to detoxify as well. Reduce your alcohol intake or eliminate it for some time. Our liver cells regenerate every six weeks. Give it a break to help. 

A good supplement is dandelion tea, milk thistle tea. They are really supportive for your liver as well. Incorporating these into your diet. 

From a lifestyle perspective, reducing your toxic load. We are surrounded by toxins in our current 21st century, modern life. It’s hard not to get exposed to it. Let’s control what we can within your house. 

Starting with your water. Having a good filtration system is important. Do not drink tap water please. That’s one tip. 

Your personal care products and cleaning supplies. Cleaning those out slowly. We know they have a ton of chemicals that can be endocrine disruptors. Knowing your liver has to work through those as well. 

If you are taking over the counter medication, watch how much. Your liver has to process those as well.

Putting in an air purifier. 

Taking out plastic. Slowly reducing your use of plastics can help your liver indirectly. 

Exercise is super important. Sweating. Skin is the largest organ. It helps us detoxify. Getting exercise, 15-20 minutes of high intensity, just to sweat. 

If for whatever reason, if someone is injured or in later stage pregnancy, when it’s not good to get high intensity in, leveraging saunas is a great way to sweat. 

Dry brushing is a simple practice right before you shower. 

One of the latest ways for me to support my own liver health since I don’t have a gallbladder is using castor oil packs on your liver overnight, or for 20 minutes a day. This can be supportive for your liver health.

When we get into supplements, since I don’t have a gallbladder, I support and depend on getting the bile salts, ox bile, and hydrochloric acid. I know this is something we can touch on as well. This thoroughly supports our digestion. Those three. 

Also, adding ACV. If you still have your gallbladder and liver, have ACV and water before meals to kickstart the production of the right enzymes to help break down food. 

With any supplement, my rule of thumb is start slow, and see how it works. Everyone’s body is very different. I am very sensitive. If I take a bunch, it doesn’t really suit me. I have to go slow, wait for a day to see how you feel before you add on. 

That’s similar with leveraging fats in your diet. Some people may do okay. When I was going through the flare, the doctor said, “You have to be watchful about high fats. You don’t want to add more fuel to the fire.” Taking a break at that point. Your body might be okay with some healthy fat or not, but you have to be in tune with your body and aware of how it’s working. 

Those are how we can support our liver and gallbladder health. If you have a gallbladder, to save it. If you don’t have one, you really do have to- That’s why I take bile salts, especially with my high fatty meals and digestive enzymes to help support my health. 

I work on the gut a lot. Gut has been so crucial. It’s work. It didn’t happen overnight, but over the years. Working on my gut and reducing my toxic load and cleaning up everything that’s around me that I can control has helped. Our body always wants to work for us. It’s never against us. It’s our friend. Give it the right support. Figure out the dance. It’s a new dance without the gallbladder, but it figures it out. 

Dr. Eric: 

Since you don’t have a gallbladder, you mentioned how you take bile salts regularly. If someone doesn’t have an underlying gallbladder or bile metabolism issue, is it at all harmful to take bile salts? Let’s say if they’re not sure, and they just on their own- I know you can’t give advice and say to generally take bile salts. Do you know any harm in taking ox bile if someone doesn’t have an underlying problem? 

Divya: 

First, start with food and herbs. Those are very safe to start with. Adding ginger into your meals and apple cider vinegar, everyone can benefit from that. If you don’t have a bile metabolism, start there first, and see how your body does. If you do want to start with an ox bile salt, start slow. Work with a practitioner. Talk to your doctor about any outward risk of taking it. 

Take a small quantity with a high fatty meal to see how you do. If it’s not working, you may get diarrhea, loose stool, if it’s excessive bile salts. That could be an indication that it was a little too much, and you need to back down and stop. That could be one way to try it out. 

Dr. Eric: 

Good to know. If they are taking bile salts, and they don’t need it, they might develop some loose stools or digestive issues. Pretty much listen to your body. If you are taking anything and notice any type of side effects, it might be a good idea to take a break from that. I wanted to know what to look out for, so I’m glad you brought that up.

Neither one of us can tell people to get surgery or avoid it. Obviously, we both would prefer for people to avoid it whenever possible. It’s a little bit tricky. There might be people who have similar symptoms, and they’re wondering if it’s too late. Can they avoid surgery? 

I don’t know what your thoughts are. I have never given birth. I have never had my gallbladder removed. You mentioned earlier how the gallbladder pain was worse than giving birth. I imagine if you’re in that much pain, it probably is a sign that you don’t want to just take apple cider vinegar or ox bile. You should probably go to the ER at least. 

Assuming it’s not that extreme, what would you recommend? Would you recommend still getting checked by a doctor, getting a CT scan, seeing if there are gallstones? 

Divya: 

As Dr. Eric mentioned, work with a medical professional when/if you’re dealing with gallbladder attacks or issues. Yes, I believe we need that organ. It was there for a reason. I don’t think God or whichever faith you believed in designed us in such a way- It was very thoughtful in how everything has its place. Even the appendix is needed, and it shouldn’t be taken out.

There is a time and place. If there is extreme pain, where you are throwing up and having fever and chills, that could be the only option that could save your life. You don’t want your gallbladder bursting inside as well. Maybe in that scenario, if it’s filled up with stones, there is no going back at that point. 

Paying attention to your body. If you can catch it earlier on. If you are feeling right shoulder pain, indigestion, looking at your basic liver tests. If you pick it up early enough, maybe applying some of the supports we just talked about could help. Working with a practitioner could help with removing the inflammation that could be going on. Getting the bile metabolizing early. If it’s just one stone, there could be ways to dissolve that stone earlier on. 

I would highly recommend and request if there is a gallbladder issue, to get your thyroid checked. As we talked about, there is a connection between your thyroid, liver, and gallbladder. If you are facing liver or gallbladder issues, get a full thyroid panel, not just your TSH. On previous episodes, you have talked about free T3, T4, reverse T3. Get all of those numbers checked. And vice versa. If you have Hashimoto’s or any thyroid condition, even hyper, take a look at your liver and gallbladder health.  

Dr. Eric: 

You work with people who have gallbladder issues. If someone is suspecting a gallbladder issue or bile metabolism issue, if they are not sure, or if they have been diagnosed, and they are trying to do everything they can to avoid surgery, they could always consult with you and get your opinion. If you think it’s something you could help with, you will. 

Divya: 

Depending on where they are. I can work collaboratively with their doctor. Adopt some of the right supplements, nutrition, diet, and lifestyle changes to see how well they implement. Also, my protocols will always have liver and biliary support because I think all of us can use some help in that department. I do help people with that. 

Dr. Eric: 

Divya, this has been wonderful. Is there anything else you wanted to cover? Any final thoughts? 

Divya: 

After going through my health journey, I don’t wish anyone else to go through what I did. With the rise in gallbladder issues that we are seeing. If people start paying attention to their liver and gallbladder health, even if they are dealing with diabetes, and you notice other issues- Our body is interconnected. It’s working really hard underneath to keep it in balance. By the time people start seeing abnormal blood reports, it’s been dysfunctional for a long time. 

Start with the basics. Start changing your diet, lifestyle. Those have had a huge impact on my own health with just making changes there. It takes time. You have to be consistent. I wish there was a magic pill. I wish it was easier. It takes time and effort, but the results are worth it. 

You want to live on your own terms. You want to live for as long, enjoy the things, travel. Whatever your goals and hobbies in life are. Paying attention to that. Getting more attuned to your body as well. 

All of us are so disconnected with our body. We somewhere have lost our connection with ourselves, with what’s going on. We don’t pay attention to the little nudges our body gives us. It’s not until it says, “You’re not listening to me.” 

Maybe that’s what happened to me, right? My gallbladder was yelling at me. Maybe there were signs it was giving me, and I didn’t know to pay attention to those at that point. Pay attention to your body. It’s your friend, not your enemy. I wish everyone well. Get the right support, ask the right questions, and be your own health advocate.

Dr. Eric: 

Thank you. Where can people learn more about you? If you could share your website, any social media.

Divya: 

Absolutely. People can find me on my website, DivyaGupta.net. It’s a very common name, so .com was taken. I have a very helpful guide there. It’s a comprehensive Hashimoto’s symptoms guide and comprehensive lab descriptions. With Hashimoto’s, or subclinical, it manifests differently for different people. My symptoms look different from yours. I have a good list of all the labs they would want to run. They can get that from my website.

I am on Instagram as well, @_DivGupta. It’s where I spend time. Those are the two places people can find me. 

Dr. Eric: 

Wonderful. Thank you so much. This was a wonderful conversation, as far as gallbladder health, liver health, bile metabolism. You covered a lot. I’m sure the listeners learned a lot of things. I learned some things, too. It was really a pleasure chatting with you. 

Divya: 

Same here, Dr. Eric. Thanks so much for what you do. You have amazing episodes. I am learning as well from you. Graves’ and hyperthyroidism is a space that I am interested in. I have been more on the Hashimoto’s side. Thank you for putting out such great interviews, bringing on great experts on your show that we can all learn and benefit from. Thanks so much for having me on the show. 

Dr. Eric: 

You’re welcome. Thanks for those kind words. I appreciate it. 

Recently, I interviewed Megan Lyons, and we talked  the relationship between nutrition and thyroid health, the benefits of antioxidants, healthy fats, and proteins, concerns about goitrogens in cruciferous vegetables, phytoestrogens in soy, whether a gluten-free diet is necessary for thyroid patients, the impact of oxalates, Megan’s perspective on natural sweeteners, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am excited to chat with today’s guest, Megan Lyons. We are going to be doing a deep dive into nutrition, talking a little bit about thyroid health as well. Let me go ahead and dive into Megan’s bio.

Megan Lyons is a sought-after health and wellness expert who is deeply passionate about inspiring others to feel their healthiest and happiest. Megan is a Harvard graduate MBA and former management consultant who left the business world to follow her passion for wellness by opening The Lyons’ Share Wellness in 2014. 

Since then, she has earned a master’s degree in holistic nutrition, become double board-certified in holistic nutrition and clinical nutrition, and is currently pursuing a doctorate in clinical nutrition. She is a master of 10,000+ hours of one-to-one nutrition counseling with clients internationally.

Megan runs a top podcast on health, Wellness Your Way with Megan Lyons. Her Revitalized Health Accelerator is a community of like-minded individuals looking to continuously uplevel their health and wellness. Thank you so much for joining us, Megan. 

Megan Lyons: 

Thank you so much. I’m really excited to be here with you today. 

Dr. Eric:

 I’m also excited to chat with you. Let’s get started by giving a little bit of your background. Why did you choose to leave the business world and enter the world of nutrition? 

Megan: 

I think like many of our stories, it started with myself. I grew up as a high-achieving kid who didn’t really think too much about health. I danced all through my childhood and even through college, but I never really considered exercise or nutrition at all. 

In college, I saw a cute guy actually on move-in day. He was on the track and cross country team. I thought, hey, I should probably start running if I want to get his attention. I did start running. I ended up marrying him several years later. Now it’s been 20 years since that. 

Like I said, I was a high-achieving kid. Anything that I started doing, I did too much. I did over the top. I started running too much for my body. I started trying to learn about nutrition. In those days, we didn’t have social media or as much internet access as we have now. It was all magazines and some books, but I was reading fitness magazines, Self, Shape. What I was reading was, “Eat half a protein bar for lunch. Be on the elliptical for two hours a day.” I did it. Like any good high-achieving kid, I kept going and going. I eventually burned myself into the ground.

I was 23 when I went into a doctor’s office and said, “I feel terrible.” They thankfully ran my hormones, which actually looking back, I’m somewhat shocked that they did. I’ll never forget the doctor looking at me, and she said, “You’re 23 years old, and your sex hormones are lower than the post-menopausal women that I work with. I don’t know what’s going on. You must have to be on medication for the rest of your life.” 

I just knew that wasn’t the answer. I didn’t know what the answer was, but I knew that I was doing this to myself, not in a shaming way, but in a way of if I can take responsibility for this, I know I can figure out how to change it. 

That started me into learning about real nutrition and health. I always like to say once you feel it for yourself, you can’t help but share it with the world. It did take me several years to actually make that decision. I went back to consulting. But it was burning so much inside of me that I just had to share it with other people. I started The Lyons’ Share Wellness in 2014. Here we are. 

Dr. Eric: 

Pretty cool story. Funny you mentioned, well, not funny, but you mentioned the overtraining. As we were chatting before, I have a history of Graves’, and I’m sure that was one of the contributing factors. Before I was diagnosed, I was overtraining and dieting. I didn’t at the time think I was overtraining, just like probably you didn’t think when you were running two hours on the elliptical. You felt great when you were done. 

Megan: 

Correct.

Dr. Eric: 

The more, the better. I didn’t think that either. At least you had an excuse. You were 23 years old. I was older. I was graduating chiropractic school at the time. I didn’t listen to my body. Definitely not only emotional stressors, but those physical stressors could play a role, too. 

I wanted to start out by talking about some of the beneficial foods, just because we will definitely talk about gluten and other foods you should avoid. I want to start out on a positive note. What are some foods that you recommend for people with thyroid conditions to eat, or just in general? What are some of the healthier foods? 

I don’t know if there is a difference. If someone walks into your office, or virtually, and someone has a thyroid condition, whether it’s Hashimoto’s or a non-autoimmune condition, or just someone with a different condition, if the foods vary. Feel free to go anywhere you’d like to with this.

Megan: 

I think of them as two circles: thyroid and general health. But the vast majority of those two circles, maybe 90%, do overlap. There are very few conditions that the nutrition is completely different from the nutrition guidance I would give to the average person, which is nice. It makes it a little bit easier. Of course, there are various tweaks for every single condition. 

When it comes to what overlaps with general health, at first, I like to think about really nourishing our body, which we do through all of these wonderful antioxidants and polyphenols and all kinds of good chemicals from plants in particular. Berries are some of my favorite foods to recommend. Dark leafy greens are really rich in these polyphenols. All kinds of vibrant colors of vegetables and fruits.

Then I also like to think of really good quality healthy fats, which are important for all kinds of hormones, thyroid hormones included. Avocadoes, olive oil, nuts, seeds (to tolerance, depending on the person’s gut health), olives, foods like that.

And good quality protein as well. Bone broth tends to be one that is generally very well tolerated for people with thyroid conditions and otherwise. But that is a very soothing food. All kinds of good quality proteins. We can talk about what that means.

If I’m thinking of some foods that I would particularly recommend to patients with thyroid conditions, I think we often hear about selenium and zinc, which are important. If I didn’t know anything else about the person aside from they have a thyroid condition, I probably would recommend some foods rich in selenium, like Brazil nuts, or in zinc, like oysters. There is a lot more to know in terms of whether or not we need to focus on those nutrients or not. But that’s where I would start.

Dr. Eric:

 I want to talk a little bit about bone broth. I would think you would agree that if someone is willing to make their own bone broth, that would be best. If someone doesn’t have the time, they just want to go out and buy bone broth, is it okay for them to get it, assuming it’s a good quality, organic, grass-fed beef bone broth, for example? 

Megan: 

I say yes. I am very big into let’s make this doable for the person. You’re right. If we’re willing to make it at home, it is the best. I resisted this for a while because the thought of putting bones in my Instant Pot was strange. Honestly, it’s really not that bad. It’s incredibly easy. It takes about four minutes of hands-on time. I find at my local butcher I can get some extra bones that I know have been well sourced. 

Just like you said, if that doesn’t feel sustainable, there are several brands out there. I have zero affiliation with these brands. Bonafide Provisions, Kettle & Fire, there are many others that are making good quality bone broth. That’s a great place to start. 

Dr. Eric: 

I agree with that. One thing I want to get your opinion on is cruciferous vegetables. There is a little bit of controversy with cruciferous vegetables and thyroid health, the so-called goitrogenic properties of broccoli, kale, and cauliflower. What is your opinion here? 

Megan: 

I tend to believe that most foods that nature made can’t be that detrimental to us until we overdo it. It is true that cruciferous vegetables have goitrogens, so they are goitrogenic, which can inhibit the thyroid. But actually, it’s not just cruciferous vegetables. A lot of vegetables and other foods have goitrogenic properties. 

It’s all about the dosage. If someone is coming to me with a thyroid condition and saying, “I eat seven cups of raw broccoli per day,” absolutely. I am going to help them change to a different type of vegetable, or at least help them cook their broccoli really well, which can help neutralize some of that.

I don’t think that it’s necessary for the vast majority of people with thyroid conditions to completely take those foods out. It’s all about quantity and moderation. There are so many great properties of those foods that I would hate for us to completely eliminate them. I’d also love to hear your thoughts on that. 

Dr. Eric: 

I definitely agree that I think in most people, it’s not going to be a problem. I recommend them. Again, I do see a lot of people with hyperthyroidism, so if that was the case, I still probably wouldn’t say no. Again, people with hyperthyroidism would probably rather eat broccoli and cruciferous vegetables than take antithyroid medication.

Experimenting with that, I intentionally tried using larger amounts of cruciferous vegetables in patients years ago to see if that would work. Some of my hyperthyroid patients, specifically pregnant women who didn’t want to take medication. Obviously, it didn’t work. 

Maybe if someone is eating a massive amount of raw cruciferous vegetables. As we both know, usually that’s not the case. Most people, we need to encourage to eat more vegetables; they are not eating too many vegetables, even one specific vegetable. I agree with everything you say here. 

Now you did mention that cruciferous vegetables aren’t the only goitrogens, which is true. Another goitrogenic food I want to talk about, which we don’t need to get into the goitrogenic properties, is soy. I want to get your perspective on soy. 

It’s goitrogenic, but there are other reasons. A lot of practitioners will say to avoid soy, not necessarily for the goitrogenic properties, but for genetically modified, if it’s not organic. Lectin potentially in soy. I wanted to have your perspective. I definitely will give my perspective after you share yours. 

Megan: 

Great. I’m interested to hear it because I think this is one of those things that just like eggs, we have flipped so many times on this. This is in part what is frustrating to people about nutrition science. Also, what can be exciting to us as practitioners because we are constantly learning more and figuring out how to actually do nutrition studies. Of course, we can’t and don’t want to lock humans in a cage for 50 years, but that makes it hard to do appropriate nutrition studies. Now, we are just learning how to do it better, so we get better information.

That said, my read of the research on soy is that there are actually some beneficial properties to the natural phytoestrogens from soy, if it’s consumed in whole forms. In edamame, especially organic, non-GMO edamame. Or in maybe some sprouted, organic tofu, something like that. I don’t have people shy away from those whole food forms of soy.

Now, where I will change my tone is a lot of soybean oil, soybean lecithin in everything, soybean who knows what else, all the processed derivatives of soy. I do think that there is such a thing as too much of that. Whole food soy, especially in organic, non-GMO forms, I will support. 

Dr. Eric: 

I agree. I will admit if I have someone following an elimination diet, initially I will have them avoid soy, almost to play it safe, mainly because it is a common allergen. 

With that being said, organic fermented soy has some great health benefits. I’m not really concerned about the phytoestrogenic properties. I agree with you. I have done research with that and flaxseeds. I think it’s beneficial. Estrogen gets a bad rap. People’s concern about estrogen dominance, eating soy, eating flaxseeds, those are not going to cause problems. If anything, they might be beneficial.

Megan: 

Exactly. It’s a lot about how we process the soy. If we have a damaged gut or our detoxification system is not working well, then we are recirculating a lot of those estrogens. That can be negative. If our body is healthy and operating appropriately, phytoestrogens from soy and flax especially should not cause a problem. 

Dr. Eric: 

I agree. I also agree with what you said before. Drinking soymilk or soybean oil or the most processed forms, I do recommend for people to avoid those. We’re on the same page with that as well. 

Gluten, we’ll get this out of the way. Do you recommend, at least while healing, to avoid gluten? 

Megan: 

I really pride myself on not being all or nothing, black or white, yes or no on almost everything. For people with thyroid conditions, and honestly a variety of other autoimmune and even non-autoimmune conditions, I do think that a period of 100% gluten-free is important for healing. 

I know it breaks people’s hearts to hear this. Some people actually in my practice find it easier as opposed to saying, “Oh, I’m going to have sugar once a week. I’m going to have an alcoholic drink once a week.” Just saying no gluten is easier. 

That was the case for me. I don’t have an autoimmune thyroid condition. For me, I realized, based on my hormonal issues in the past, my gut issues, all kinds of reasons, and the fact that our gluten today is not that healthy and sprayed with glyphosate and all kinds of other things, it was easier for me to say 100% no. I haven’t looked back. It’s been 11 years or so, maybe more, for me. 

I can tell you that it’s really not that bad. But I understand my clients’ reaction when at the beginning, I say, “Let’s go gluten-free for a few months,” and it looks like their brain might explode because it feels overwhelming. Of course, we walk them through it. I do think that at least in the initial period of healing, we need to eliminate it. I would love to hear your thoughts as well. 

Dr. Eric: 

I definitely agree. If someone is eating whole healthy foods, then it’s not that difficult. Making that transition, if someone is not eating whole healthy foods, what some people will do is eat gluten-free cookies and other things that are gluten-free. I can’t say I never eat those foods. 

Sometimes I joke around and say it’s been years since I’ve had Graves’, so I can’t say I never have pizza, like a cauliflower crust pizza for example. While healing, I would usually say to take a break from even those foods. Just because it’s gluten-free doesn’t mean it’s healthy.

I do agree that for some people, it’s not a big deal. “As long as I don’t have to give up my coffee,” for example. You’re right. For some people, it is a big deal. For others, there are other foods or beverages that they don’t want to give up. They don’t want to give up coffee, but they don’t mind giving up gluten.  

Megan: 

Yes, I agree.

Dr. Eric: 

Speaking of coffee, I tell people to take a break from coffee even though it does have polyphenols and other health benefits. It’s not a forever thing. What is your perspective as far as coffee? Does it depend on the person’s condition that they are presenting? 

Megan: 

I think the latter. It depends for me on the person. The reason is that many thyroid conditions are related to that HPA, hypothalamic pituitary adrenal, or HPT, hypothalamic pituitary thyroid, axis. A lot of it can be stress-based or sympathetic nervous system-based. Even if I change that word “based,” maybe “related.” There is something going on with the balance between sympathetic and parasympathetic. Coffee and caffeine as stimulants do not allow us to heal that balance. 

I do drink coffee personally in moderation. And I think there are many benefits to the polyphenols and, even some of the studies show, the actual caffeine in coffee. 

During that healing period, for a lot of people, I will help them find alternatives. There are great alternatives out there that are maybe chicory-based, coffee/herbal beverages, or other things that can mimic the taste of coffee. Oftentimes, once they get over that initial “that seems scary,” they find the substitutes to be just fine. 

Dr. Eric: 

That’s good news these days. Even though we said just because something is gluten-free doesn’t mean it’s healthy, when someone is on a wellness basis, and they want to have gluten-free pizza or cookies, there are, in my opinion, delicious options, compared to 10-15 years ago when gluten-free pizza would taste more like cardboard. There weren’t as many options. 

Same thing with coffee. There are a lot of good coffee substitutes. I am not a coffee drinker, so I can’t say I have tried all or most of them. My wife is a coffee drinker like you. Also, a lot of my patients, they’ve had experience trying different types of coffee substitutes. You’re right. There are a lot of healthy options out there for those who are coffee drinkers but are taking a break from it. 

Megan: 

Yes. 

Dr. Eric: 

How about dairy? What are your thoughts on dairy while healing, and as far as reintroducing it eventually? 

Megan: 

I put dairy in between coffee and gluten, meaning gluten is 100% for almost everyone with a thyroid condition, and coffee, I would say maybe 50-60% of my clients who have thyroid conditions end up taking a break from coffee. Dairy is somewhere in the middle. 

I think if we had a healthy, robust gut and immune system, a little bit of good quality dairy would not be a problem for most of us. There are a lot of caveats to that sentence. Most of us don’t have healthy guts. Most of us don’t have healthy immune systems, especially with autoimmune conditions. 

Healthy dairy is honestly very hard to find in the United States because we are pumping it with so many hormones, antibiotics, etc. The quality of dairy we get. 

And the frequency of consumption, which is a lot. Many of my clients, without even knowing it, are consuming dairy 7-8 times a day with milk in their coffee and cheese on their eggs and cheese on their salads and cheese for a snack and maybe ice cream after dinner. We just know that not only can dairy be mucus-forming and make us not feel as great, but it can incite that immune response in our bodies. We just want to cool all of that stuff off when we are initially healing the thyroid.

I do tend to believe that many people can reintroduce dairy, especially good quality, maybe some real yogurt or some hard parmesan cheese or something like that, after a period of time. 

Dr. Eric: 

I can’t say that I never eat dairy. I don’t eat it every single day, but I’ll have it maybe a few times a month. Sometimes, I might go a few months without it. As far as things like yogurt, I am personally fine with having coconut yogurt. Same thing with ice cream. I have two teenage girls, so I can’t say I never have any regular ice cream. But I’m fine with the alternatives, too. You have to be careful. Just because it’s alternative, that doesn’t mean there isn’t other stuff in there, so be careful when reading ingredients. Do you currently have dairy at all? 

Megan: 

Dairy is a funny thing for me. I love yogurt. You’re right, there are great yogurt options out there. I just really love yogurt. And cottage cheese, too. I really enjoy it. Even ice cream. I’m great with the coconut milk alternatives, coffee creamer, no problem. Yogurt and cottage cheese, I love.

What happens is I will say, “I’m feeling great. I’ll bring dairy in for a while.” Then I feel great. Then six months go by, and I realize, “Oh my gosh, I just consumed dairy twice a day for the past three weeks. I’m really pushing my boundaries.” As we’re recording this in early February, in January, I did zero dairy for myself, just to reset. Just like you, I’m okay with having it 1-3 times a week. But I know for me, there is a limit. I just need to reset myself every once in a while. 

Dr. Eric: 

Listen to your body. Everybody is different. There might be people listening to this who are saying, “I’ve been eating dairy daily for years.” That was me years ago. The problem is that a lot of people, if not most people, are eating the unhealthier forms of dairy. It’s one thing if they’re consuming raw, unpasteurized, not homogenized dairy in the healthier forms. If someone is just drinking regular milk, even if it’s organic, it’s still processed. At least in my opinion, it’s still not ideal to have that every single day. If someone wants it now and then, it really depends on the person. 

Megan: 

I agree. I have some funny genetics for a lot of reasons. My mom has terrible gut health. My dad has wonderful gut health. He is 75. He has been drinking milk every single day of his life. He eats a lot of cheese. He is honestly fine. I have switched him thankfully to organic and better quality, but he is still drinking organic milk out of a carton, and he’s fine. I just know that is not my case. My mom for sure, not either. Like you said, listening to your body on this one is really important.

Dr. Eric: 

Let’s talk a little bit about oxalates. I was listening to some of your previous interviews on other podcasts. Oxalates are a hot topic. I know your thoughts because I listened to the interview, but I want you to share your thoughts with these listeners. 

Megan: 

Oxalates are a hot topic, just like goitrogens and some others. I honestly think 1) the real foundational principles of nutrition are just not fancy enough to sell very well. If everyone every day says, “Eat more vegetables. Drink more water. Eat less sugar,” it gets boring. People want something else.

2) People want something to demonize. I am not here arguing that oxalates are not a real thing. They are. They can be a problem. Certainly, if someone has existing kidney issues or a variety of other conditions, will I have them be aware of oxalate consumption and reduce it? Yes.

For the average person, I don’t put people on a low-oxalate diet. Just like the cruciferous vegetables, if I notice that someone is putting five cups of spinach in their smoothie, and they have a spinach salad, and they are having kale chips for a snack, there is a good chance I will either run an organic acids test or check in with them to see if they can substitute some of that. Otherwise, I don’t think people need to be afraid of spinach or kale or any of the other foods with oxalates, unless there is a known issue.  

Dr. Eric: 

Funny you mention the organic acids test because I have been having smoothies for years. In the past, I would stuff it with spinach and didn’t really think anything of it. I did an organic acids test and had high urinary oxalates. That doesn’t guarantee that I have kidney stones or other issues, but at the time, I figured there were other substitutes. It’s not like I can’t or shouldn’t have any spinach ever again. Maybe I was overdoing it with the spinach. At the very least, it taught me to diversify more. 

I don’t recommend for everyone to follow a low-oxalate diet, but there are other substitutes as well. Same thing. If I see someone overdoing it, I will say something. 

I don’t know if you are familiar with Sally K. Norton. She has a book called Toxic Superfoods. Very interesting book, which focuses on oxalates. She was on the podcast. 

Again, it’s very interesting. She is research-based. One of the foods that is higher in oxalates is sweet potatoes, which I commonly recommend to people. Since then, I still haven’t stopped. I don’t say everyone needs to cut out sweet potatoes. But I am more aware of how certain foods are high in oxalates, and there are some good substitutes. Not to say never to eat those foods, but there are other options. 

Things like sweet potatoes, I usually have people avoid white potatoes while healing, too, so sweet potatoes. “I look forward to my sweet potato every day” for some people. I have been recommending them for years, and I can’t say I have seen problems with people eating sweet potatoes and some other higher oxalate foods.

I admit since the interview, it’s been more eye-opening. Like I said, I am more cautious. Berries, for example. I can’t say I never add blackberries and raspberries to my smoothie, which are high in oxalates. Blueberries, according to Sally, are not, and cranberries are not. It did make me aware. 

I was rotating anyway. It’s not like I was adding blackberries every day. If I was, I probably would start rotating. 

For the listeners, I would say if you love blackberries or raspberries, I am not saying to give them up. Sally K. Norton may say that. There are substitutes if you wanted to. At the very least, I would say to rotate. That is the case with all these foods. You shouldn’t be eating spinach every single day. Anyway. I’m of the mindset that it’s good to diversify. 

Megan: 

I agree completely. Diversification is so important with food. I am one of those people who I could eat the same breakfast every single day for the rest of my life, and I would be just fine. I don’t crave that much variety. 

But it really is important to try to break out of our ruts and rotate our foods, so we don’t develop these intolerances, and we get an abundance of nutrients. I do encourage people to do that, to the extent that it’s reasonable. I am not someone who says, “Oh my gosh, you ate asparagus yesterday. You can’t eat asparagus today!” Let’s not get too dogmatic about it. But get some variety in there.

One more thing I wanted to say for the sweet potatoes. Have you ever tried parsnip fries? They’re really great. A parsnip is a white-looking carrot. You can cut them in fry shapes and roast them in the oven. They have that same mouthfeel as potatoes and sweet potatoes. 

Dr. Eric: 

Interesting. I didn’t know that.

Getting back to eating something different every day. When you go grocery shopping, and you get whatever vegetables, you want to use it up before it spoils. You might use it a few days consecutively. To me, that’s normal. I guess the person who, every time they go to Whole Foods or a farmer’s market or wherever they are buying, if they keep on buying the same exact vegetables every single time, if you want to buy whatever batch of vegetables you get, use them up for however long it takes, and next time you shop, get some different ones. I think we agree on that. 

Megan:

Yes, we do. 

Dr. Eric: 

Can you overdo it with fruit, in your opinion? Can you eat too much fruit? 

Megan: 

I think yes is the answer, but most people are not. I will never forget, at the beginning of Instagram, whenever that was, there was a guy who called himself the 40 Banana a Day guy. I don’t remember his real name. He was literally eating 40 bananas a day. I just think that’s too much. There is no other way to put it. 

If you are that guy, then let’s make a change. But most people, I don’t think that having, let’s say, a serving of fruit with breakfast, and maybe a serving of fruit as a snack, and then maybe even you’re sprinkling a couple of blueberries on some coconut yogurt after dinner, that’s several servings of fruit. I don’t think that’s the issue. 

There are some people with severe dysglycemia who I see who I might work on paring back, especially those tropical fruits, like papaya, mango, even banana, pineapple, all of those kinds of things. Trading them for lower glycemic fruits. 

But we are demonizing the wrong thing. If we look at the spectrum of sugar-laden foods, and we are worrying about our blueberries or apples, and we are still allowing candy and sugary creamers and sugary dressings and sugary yogurts, we are probably focusing on the wrong part of the spectrum in my opinion. 

Dr. Eric: 

I can’t imagine anybody eating 40 bananas, let alone 40 of any food, just fruit. 

Megan: 

Yeah. 

Dr. Eric:

Even one a day. 40 bananas in a single day, let alone every single day. That’s crazy. 

Megan: 

It sounds terrible. I can’t imagine he felt good. He was getting popular, so maybe that felt good. But no. People just take everything to extremes. 

Dr. Eric: 

Yeah. I agree. Let’s talk about natural sweeteners. I’m sure you would agree to try to avoid artificial sweeteners. If you don’t, let me know your thoughts on those. I’m thinking sucralose, okay. How about things like stevia, monkfruit? What are your thoughts on those and other natural sweeteners? 

Megan: 

I personally consume stevia and monkfruit. I would not say on an excessive basis. Those are not things I shy away from.

I think the jury’s still out on these. I don’t think we have enough research to be conclusive on stevia and monkfruit. I do think we have enough research to be conclusive that sucralose, aspartame, potassium, all these disrupt our gut microbiome and can lead to negative outcomes. 

Stevia and monkfruit, the research is new in my opinion. I believe that because they are naturally based- I will also say we have to be very careful at looking at labels. Some of the packets of stevia is like the last ingredient. It’s not stevia. It’s dextrose or erythritol or whatever else. Really make sure you’re getting stevia or monkfruit. I feel, based on the limited amount of research that exists, that those will be much better alternatives.

One more caveat is they can definitely change our tastebuds. I notice in my clients people who are having six packets of stevia in their coffee, and they have to put stevia on their strawberries. They don’t appreciate the natural sweetness of real food anymore. That leads to increased sugar cravings. I would say have caution. 

My current read of the research is a little bit of those is gonna be fine. I’d love to hear your thoughts though. 

Dr. Eric:

I agree. I don’t go out of my way to avoid those. I’m not a coffee drinker, but I drink green tea and herbal tea. I used to add stevia to them. Then I stopped. First, I added stevia, and then I was also adding honey. If I had a choice, honestly, I would add a little bit of honey. Over the last couple of years, I have had it without having anything. 

Part of it is also the fasting, which I want to talk to you a little bit about. There is still controversy whether stevia causes an insulin response and breaks the fast. I don’t think green tea by itself does. I just stopped adding anything to green tea. Herbal teas to me are pleasant even without sweetener. It was the green tea that I can’t say I absolutely love; I just drink a cup in the morning for the benefits. Then I pretty much drink herbal tea after that.

I haven’t seen anything negative with monkfruit. I know with stevia, potentially, there is some research that it could affect fertility. I forget if that’s human studies or rat studies. Just to play it safe, if someone is trying to conceive, they might want to take a break from stevia. Maybe it won’t prevent them from getting pregnant. 

Megan: 

Yeah, I’m not sure if this is the same study, but it might be. The one that I saw relatively recently, the stevia part was in the headlines, but it was actually lumping stevia, sucralose, other artificial sweeteners together in the study group. I’m not sure.

I agree. There is zero harm in taking stevia out of your diet, especially if you have concerns like fertility. Why not go to a little bit of honey or train your tastebuds to enjoy herbal tea without any sweetener? I think that’s not a bad idea in any form. 

Dr. Eric: 

Let’s talk about fasting. Let me give my thoughts on fasting. I mentioned how I do some fasting. When I dealt with Graves’, this was 2008-2009. Fasting wasn’t the hot topic that it is today. At that time, I was losing a lot of weight. I wasn’t in a really good state of health. I would definitely not have wanted to fast then given the situation.

I do incorporate intermittent fasting. Typically, I will go 14-16 hours, sometimes a little bit longer. I try not to do extreme fasts. I listen to my body. I do see people doing extreme fasts. I had a patient who was doing 20-hour fasts. It seemed like she wasn’t getting enough protein in that four-hour window, as it was every single day. She was doing it to lose weight.

I can’t say I encourage people necessarily to fast. I tell all my patients while healing to fast. It depends on the situation. Many times, I will discourage people from fasting if I don’t think they’re ready for it. 

I guess in a nutshell, I do fasting, but I don’t think it’s a perfect fit for everyone. I think some people can definitely benefit from it. Other people might need to heal their adrenals and overall put it on the backburner until later. 

Megan: 

Yes. I completely agree with that sentiment. There is incredible research on the benefits of fasting for autophagy led by Walter Longo and others; digestion; healing all kinds of various conditions. And most of that research is either done on mice or on middle-aged, non-stressed men. Most of the clients that I see are not mice or middle-aged, non-stressed men because that’s really hard to fit all of those categories.

Do I think the benefits can extend beyond that? Yes. But it becomes more complicated with women. I do think women can fast. Women who have healthy relationships with their body, who are in a stable thyroid and hormone condition, even if that’s post-menopausal. Post-menopausal women are great candidates for fasting. If you’re going through a tumultuous time with your hormones, thyroid, emotions, or stress, I don’t think it’s the time for fasting. 

Fasting is a stressor. Just like exercise or any other hermetic stressors—which basically means if it doesn’t kill you, it makes you stronger—there is benefit. If our cup is already too high from stress, I am very emotionally stressed. I am dealing with whatever kind of social situation. My thyroid is out of balance right now. I’m trying to get pregnant. Or something like that. All these stressors. Fasting is definitely not the right move for you.

Trying to conceive, for sure, or while pregnant, I would not recommend fasting. Very low body fat or endurance athlete, really training very heavily, severe dysglycemia. Of course, we want to get to the point where we’re more metabolically flexible, and we can handle fasting. But if you’re in the middle, that’s not the time. Eating disorder history, hyperthyroid in almost all cases, any kind of wonky hormonal imbalance. All those categories, I would say no. If you’re not in those categories, then there are great benefits. 

Dr. Eric: 

Do you incorporate any intermittent fasting personally? 

Megan: 

Listen to your body in practice. What I do for intermittent fasting, which I believe it should be normal. I don’t call this intermittent fasting in myself. I do a 12-hour eating window. That means 12 hours. If I finish dinner at 7:30pm, I don’t eat before 7:30am. I call it normal because I don’t think that should be a stretch for most people. I do think that’s healthy for most people. 

If and when I am in a low stress state, and that’s all relative. We don’t have continuous cortisol monitors although I hope we do so sometime in the near future. I can tell in my body if my body can handle it. Then I can push it more. 

I won’t do it for myself at various times of my cycle. If you are a cycling female, it’s actually better to do it in the first half of your cycle. I won’t do it in the latter phases of my cycle. I just won’t do it if I know my body is under too much stress. There are so many great things out there. We can’t pull all the levers all at once. I just pick and choose what’s right for me at the moment. 

Dr. Eric: 

Continuous cortisol monitors. We do have continuous glucose monitors, which I’d love to get your opinion on. Continuous cortisol monitors, it would be awesome if they do come out with those in the future. 

Megan: 

I think it’s coming. I really do. I am not ever going to be a person who dives into the technology world or the tech startup world. I have talked to enough people who are at least thinking about it that I just have everything crossed that’s coming. 

Dr. Eric: 

Very interesting. What are your thoughts on CGMs? 

Megan: 

I have worn over 40 CGMs in my life. Each one lasts for 10 or 14 days depending. I love them. 

I also will tell you, being that high achiever person that started my health journey, the very first time I put in a CGM, I thought, oh, this is my job. I eat really healthily. Absolute zero problem. It should be 100%. Great. And it wasn’t. That stressed me out beyond belief. 

Looking back at some of these graphs, Megan, what were you doing to yourself? I got paralyzed by the idea of any kind of glucose bump to the point where I thought, I can’t even eat one blueberry. Oh my gosh, my glucose spikes like crazy. 

Then I had this day. Dallas doesn’t go through freezes very often, but we had a very dramatic freeze overnight. All of our pipes froze in my home. I had a humongous presentation that I really cared a lot about. I was supposed to drive, and I couldn’t drive. I was just stressed beyond belief. I had not eaten anything that day. I had not exercised. I had not had coffee. My glucose spiked like crazy to 178. It was very high. 

Then I realized, okay, look back at your CGM. It wasn’t the one blueberry you had. It was the stress about the one blueberry. I had to get into that mode and realize you don’t have to be perfect. It’s a learning tool. Ever since that first or second one, I think it’s been a fantastic tool. 

The last caution I would say is glucose is not everything. Human bodies are actually designed to have a rise in glucose. If you eat your salmon and broccoli and rice, and because there is rice and broccoli, you have a little bit of a glucose bump, great. Your body is working exactly as it should. If you want to consider it as information, I think it’s a great learning tool. It’s also expensive, so consider that. But it is not the only thing. There are other important things to consider about nutrition. 

Dr. Eric: 

All right. I definitely want you to share your eight-minute morning routine. Before doing that, because of this talk of stress, are there foods you would recommend to help support the adrenals since this conversation is focused around food? Or any dietary habits? We just spoke about not wanting to do extreme fasting and things like that. Are there any specific foods you would actually recommend eating? 

Megan: 

For our adrenal health, we really want to focus on all three macronutrients: protein, fat, and carbohydrates. I find most of my adrenally driven clients are eating too low carb. Carbohydrates in a healthy form are essential for adrenal healing. We don’t want cotton candy and jellybeans. Having some really robust sources of complex carbohydrates is important. Then getting enough protein and healthy fat. All of the macronutrients are important for adrenal health.

The one interesting one that I think is in the 10% that doesn’t overlap in the Venn diagram is salt. A good quality salt in moderate doses is actually very helpful for adrenal healing. We don’t want to go too low sodium with the adrenals. Otherwise, it’s just robust sources of all the macronutrients. 

Dr. Eric: 

I’m glad you mentioned salt because that’s something. I add sea salt to my food regularly, to give it taste but also knowing that it helps support adrenals. 

Let’s talk about your eight-minute morning routine. I heard you talk about that on some other interviews you did. I’d love for you to share that with this audience. 

Megan: 

Back to my 23-year-old hormonal crisis, I realized that I was suffering from something called NTFM syndrome, which is a made-up syndrome by me. It stands for No Time for Me Syndrome. I had this mental thing that was a pity party in my head. I have no time for what I want to do. Then I realized that’s actually not true. I have 168 hours in the week, just like everybody else does, and I can carve out that time for me to create the mental environment that sets me up for how I want to feel during the day. 

That’s where my morning routine was born. I studied all the famous people’s morning routines. I came up with an acronym: WAKEUPGO. It’s eight habits, which I will tell you in a second. There is one minute for each habit. I committed myself to doing that for a couple weeks at a time. It sounds trite, but I promise you, my life changed. My morning routine is still my most important habit. I just don’t feel myself without it. It makes me so happy and balanced and productive the rest of the day. 

The eight habits. W is for water. Big glass of water first thing.

A is for Affirmations. Reading your goals, pumping yourself up for the day.

K is for Knowledge. There is a lot of great research on learning new things and brain plasticity and all kinds of great stuff. Reading a page or two of a book.

E is for Exercise. Even if you will exercise later in the day, do a minute of stretching or jumping jacks or squats to get your blood flowing. 

U is for Unwind. We take some deep breaths, meditate, journal, pray, whatever works for you to unwind. 

P is Positivity. Listen to a positive song or read a positive quote.

G is for Gratitude. We have all heard the benefits of that. Just thinking of or writing down a few things you’re grateful for. 

O is for One goal. We all have a million things on our to-do list. We tend to beat ourselves up for the ones we don’t do. Setting that one goal that will really make you feel amazing at the end of the day and focusing on that, I find to be a very uplifting habit. 

Dr. Eric: 

Wonderful. Just curious, do you actually have a timer, where it’s eight minutes? Or is it now just such a routine? I’m sure it’s not exact. If you have a timer, then it’s exactly eight minutes. If not, then I’m guessing it’s maybe sometimes a minute or two over or under.

Megan:

The real truth is I did this in eight minutes a day with a timer, just the way you envision. Go all the way neurotic with it. I did that for several years. I loved that so much that now my morning routine takes a whole lot more than eight minutes. I wake up early enough and schedule my day, so I can be more relaxed about it. Now, I’m reading for probably 10 minutes in the morning. I’m meditating for five. These things just add up. 

I have so many clients who literally do it in eight minutes. Some of them do it with a timer. Some of them do it by feel. Instead of unwinding for one minute, they just have the goal of taking five deep breaths, which takes about a minute. Just fiddle around with it, and you’ll get it to work for your schedule. The eight minutes isn’t the magic; that’s just the selling point to get people to realize they can do it if they are committed. 

Dr. Eric: 

There is a book miracle Morning, which I listened to on audio. 

Megan: 

Yes! 

Dr. Eric: 

That’s all about waking up early and getting into a routine. They check their cell phone, texts, emails, and do all these other things. I’m not saying it’s not important, but you definitely want to take care of your health first. I’m glad you shared that and are doing that yourself. That is awesome. 

You covered so many different things, which I appreciate. Is there anything else that I should have asked you that I didn’t ask you? Is there anything else you want to share? For those who are like, “Wow, so many things you wanted to cover. What are two or three things I should focus on?” 

Megan: 

I will turn the question back to the audience. I believe nutrition and health in general is only successful when it’s sustainable. Maybe people heard eight different things today that sound helpful for them. If you try to implement all eight, it will be stressful, and you’ll likely not end up sticking with it.

I would encourage people to latch onto one or two things. Maybe make some notes about those other ones, and you can do them later. One or two things to start with. 

The corollary factor to that is mindset is so powerful with nutrition, health, autoimmune healing, everything we’ve talked about today. I encourage people not to think about this as “I have to make these changes,” or “I can’t have gluten,” or “My body hates me because I have this thyroid condition.” 

Instead, think of it as, “I now am empowered with knowledge that makes me feel my best. I love my body enough that I’m going to treat it well. I get to make these changes.” It feels a little forced and silly to some people, but it truly makes a big difference. Listen to how you’re speaking to yourself. Try to be kind to your body.

Dr. Eric: 

That’s some great advice. Megan, where can people find out more about you? 

Megan:

I have a website where I have been blogging every week since 2013. There is a lot of stuff on there. I don’t even remember everything that’s on there. The website is TheLyonsShare.org. I am also @TheLyonsShare on Instagram. My podcast is Wellness Your Way. 

Dr. Eric: 

Thank you so much, Megan, for sharing everything that you shared. It was a real good conversation. You covered a lot of different things. Appreciate you taking the time to do this. Thanks also for that eight-minute morning routine, which I know now is longer. It will hopefully encourage people to wake up early. 

Quick question: What time do you wake up in the morning? 

Megan: 

I think this might have room for improvement. The real answer is between 4:40-4:50 every day, depending on what’s going on during the day. I genuinely love that time. I could obviously sleep longer and not do the morning routine. It makes a huge difference to me.

I also go to bed extremely early. That feels good to me. I prioritize my sleep. I’m in bed by 8:30pm. I would say 95% of the nights. Sleep is very important. That is the schedule that works for me. 

Dr. Eric: 

Thanks again. It was great chatting with you. 

Megan: 

Thank you. You as well.

Recently, I interviewed Dr. Aumatma Simmons, and we talked about her journey into fertility specialization, the complex factors affecting fertility, why comprehensive testing is essential, why both partners must be a part of the fertility preparation process, advanced testing methods she recommends, how thyroid imbalances impact fertility, management of thyroid conditions during pregnancy, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

Very excited to chat with Dr. Aumatma Simmons about fertility. We are going to tie this into thyroid health of course. Let me go ahead and give her very impressive bio here. 

Dr. Aumatma is a double board-certified naturopathic doctor and endocrinologist in practice for close to 15 years. She specializes in fertility and is the best-selling author of two books, Fertility Secrets: What Your Doctor Didn’t Tell You About Baby-Making and (In)Fertility: Secrets, Struggles, and Successes. Dr. Aumatma was awarded the “Best Naturopathic Medicine Doctor” award locally in 2015 and 2020. She was recognized as a top “Women in Medicine” doctor in 2020 and 2021. 

Dr. Aumatma is also the creator of Fertile Foundation Supplements, a line of research-driven nutrients that support your fertility journey. She is also the host of the Egg Meets Sperm podcast. 

In addition to supporting couples through individualized care in person and long-distance, Dr. Aumatma also trains practitioners who want to specialize in fertility. She has been featured as a holistic fertility expert on ABC, Fox, CBS, KTLA, mindbodygreen, The Bump, and other media, along with being interviewed for countless podcasts on topics of fertility, pregnancy, and post-partum health. Thank you so much for joining us. 

Dr. Aumatma Simmons: 

Thanks for having me, Dr. Eric. 

Dr. Eric: 

It’s a pleasure. I of course want to dive into fertility, but before we do that, why don’t we talk about how you became more of a specialist in fertility? I don’t know if this was right from the start, or if this was something over the years. 

Dr. Aumatma: 

It was actually a personal experience that brought me into fertility. I used just to be a women’s health doctor. I was seeing all kinds of women for all kinds of things, everything from anxiety and depression to perimenopause and menopause. Interestingly, fertility was never part of that mix. 

I was married to this person who started to talk about having children. Every time he mentioned it, I had a full-body reaction, which was “Ahhhh, no way!” We were already married at that point. It was a little bit of a shock initially. I was in my very early 30s and aware that what I had learned in medical school was fertility drops off the cliff at 35. 

I had a lot of introspection around do I not want to have children with him? Do I never want to have kids? As that was a possibility. Do I want children, and if it’s not with him, then what do I do about my fertility? Because by the time we separate, get a divorce, and then find a different person who is going to be the right person, I was looking at a very long period of time potentially between those things happening.

I did what I feel like most doctors would do. My response was: I’m going to spend every waking hour researching the crap out of fertility. Maybe this thing I learned in medical school is not actually true. Fertility doesn’t drop off a cliff at 35. I can do something about it now, so that I don’t have to worry when I’m ready. 

What I came to was two big realizations. One was there was a lot I could do that I started doing right away. Simultaneously, awareness of myself and being like, “Yeah, I actually do want to have a child, just not with him.” Working on the personal aspect while optimizing whatever I could do for my hormones and fertility. Simultaneously, realizing that this idea that fertility drops off a cliff at 35 really wasn’t based in science. Okay, if that’s not based in science, why are we giving so much credence to it? That was my process. It took about nine months. I was internal about it all. 

As I was being interviewed on podcasts about health, I would just be mentioning it. It was amazing how many women kept calling me up, “Oh my god, can you help me with my fertility?” Everything I know is theoretical. I have literally never done this before, you guys. But the number of people who were calling me was really high. 

Eventually, I said, “Yes” to this woman, and she became our first client. I said, “Yes, but you should really think about this because it’s not going to be cheap. I have never done this before. I have zero success stories to tell you about. You probably don’t want to do this with me.” I was trying to talk her out of it. She came back a few days later and said, “Nope, you’re the right person. I’m really sure. I want you to help me. I don’t care how much it costs.” She ended up being my first client. Three months later, she got pregnant. 

I simultaneously was invited into this clinic where one of my friends needed help. He was like, “Our naturopathic doctor just quit. Can you come help us?” They were a general clinic. I had no idea they had an acupuncturist who specialized in fertility. I had said yes to this thing. I walked into the clinic, and the acupuncturist was like, “I have been checking out all of your podcasts. You’re the perfect person. Here is a whole pile of cases that I have had no success with. Maybe you can help them.” This is happening way too fast. I fell into it at that point. 

I had really no reason to say no. All of these people are here and need help. No one else has been able to help them before. Let’s see what I can do. I started calling them up. “I looked over your case. I have some ideas for you. Come on in.” Out of all of those people who came in, a majority of them got pregnant that year. That was when I was like oh my gosh, it’s so amazing because obviously, the reward is huge. 

But it’s also amazing because I get to influence the health of not just that person but their child and then their grandchild all within one very short period of time. To me, from a health perspective and a person in the world, it was the perfect thing for me to be doing. That’s how I got into fertility. 

Dr. Eric: 

Awesome. How long ago was that, that very first success story? 

Dr. Aumatma: 

That was 12 or 13 years ago at this point. 

Dr. Eric: 

Wow. 

Dr. Aumatma: 

For a little while there, I was still working with some other menopause/perimenopause. Since the last 10 years or so, I haven’t taken on any new non-fertility people. I feel like if you’re a specialist in something, at least in my brain, there is no space for anything else. I breathe and sleep and dream in fertility. That’s all I want to do. That’s all I want to talk about. That’s all my focus is on. 

I feel as much as I would love to help everyone, I am very cognizant that it’s really that period of time, preconception, where I can make the most difference. It’s been about 10 years, where it’s just been all fertility. It’s always funny when people are like, “I would love to have you on my podcast. What would you like to talk about?” I’m like, “Do you know me? Do you know who I am?” There is no space for anything else. 

Dr. Eric: 

Same here. I focus on thyroid health with more of an emphasis on hyperthyroidism, even though I also help people with Hashimoto’s, because of my experience with Graves’. It’s similar. We both could help people if someone randomly came to us with a gut problem or something else. There is also only so much time we have to spend with patients. There are some people who are generalists and try to see everybody. That’s great that all you do is focus on fertility.

Let’s start off with the question: Why do so many women have problems getting pregnant? Why are there so many cases of infertility out there? 

Dr. Aumatma: 

Great question. When I started out in this field, the stats were one in eight women between the ages of 18-35—we are not even talking about all of the women who waited until later in life. We are talking about that age group who generally should be fertile. Out of that, one in eight were struggling with fertility. Now, the current stats are 1/5-1/6 are struggling with fertility. We are seeing this massive increase in fertility issues. 

It’s a multi-factorial thing. I don’t think there is one specific answer. I think it’s a combination of toxins in our environment, which are not only affecting females but also affecting the male side. It’s been said that in the next 20 years, statistically, we may have a majority of men with no sperm. This whole Handmaid’s Tale coming to life. The toxins are a piece of it, but I don’t think it’s everything.

Another big component is when people are choosing to get pregnant, women more and more are waiting until later in life. They are not being counted in those stats. There is that aspect.

There is also the aspect of stress. Everything is stress. We are all messed up because of stress. That is true to a certain extent. I would be remiss not to mention it because there are about 4,000 studies that point to how much stress actually impacts our HPO axis, which is the hypothalamus-pituitary-ovarian axis. There is an indicator that how much of what we’re experiencing in our life is going to massively impact fertility. 

Stress is such a generic term, so I don’t love using it. If there is a shift in our bodies, in our emotional experience, in the way that we view the world, where we are in survival mode, instead of creation or reception mode, then it’s going to be a really hard place to conceive. The pace of the world feels like it’s speeding up. There are more things that we are constantly worrying about. The political landscape, the wars that are happening. There is just so much. 

We may not be actively thinking about it, but it’s happening in the background. If the story that our body is creating about that is, “Hey, your priority in this moment is how do you survive,” then it’s really hard for the body to be like, “Oh yeah, I’m trying to survive, but I’m going to create another human.” On a very basic level, all of the stress that is contributing in our bodies is going to work against our fertility in a lot of ways. 

Those are the big ones that I think are across the board. Of course, we can get into hormonal imbalances, which is different from person to person. I think the factors that are impacting all of us are pretty solid and consistent.

Dr. Eric: 

Stress is big. Toxins are big. You mentioned it’s not just the female; it could be the male, lower sperm counts. I imagine when you work with someone, you obviously take that into account. Do you consult with both partners? 

Dr. Aumatma: 

In our practice, it’s mandatory that the partner is on board. We have a lot of women who are like, “Can you just work with me? You don’t ever need to talk to my husband.” No, that’s not what we are doing. There are plenty of other practitioners out there who will be happy to support you, but we’re not those people. 

Unless you are a solo mom by choice, who we do support, there is no reason your partner shouldn’t be on board, even if their sperm are great. This is the conversation that a lot of women will have reflexively. “My husband’s sperm is great. You don’t need to worry about him.” I’m like, “Sperm is the bare minimum we need to worry about. What is his lifestyle? What is his mindset? What toxins is he being exposed to? Is he methylating properly?” All of those things are going to impact not only whether you can get pregnant, but they are impacting what we really care about, which is the health of your future child. 

What is that pregnancy going to be like for you? Let’s suppose that a male has great sperm, which happens very frequently. But the DNA of his sperm is a total shitshow. He doesn’t know because there is no test that is regularly performed on the DNA of the sperm. There is a test for it; it’s just not commonly done. On the surface level, sperm look amazing. On the DNA level, sperm are absolutely not amazing. 

The woman gets pregnant, and she continues to keep having pregnancy losses. She is not sure why she is having those losses. Our society says it’s her fault, something she did. Internally, women take a lot of responsibility for fertility and pregnancy. She is also thinking, “Something is wrong with me. I’m doing something that is triggering the pregnancy losses.” When in fact, it starts with the male. 

But if he has never been tested, no one is looking at it. No one is saying, “Hey, it’s the DNA. It’s not even your sperm. It’s the DNA.” We can fix it if we just look at your epigenetics. If we dive in a little bit deeper on your health stuff, not only are you going to get her pregnant, and she will stay pregnant, but you’re impacting the health of this future baby in a very meaningful way. 

We won’t work with couples who are already coupled, already married, and the partner says, “I don’t need to make any changes.” That’s a no-go for us. I have fired people for that. “Here is a full refund. I want nothing from you. Goodbye.” It’s not what we’re about. People can do whatever they want to do. Our goal is healthier babies in this world. The how matters just as much as what the outcome is. 

Dr. Eric: 

That makes a lot of sense. You don’t want to spend all this time, and just the woman spend all this money, and three months later, six months later, find out everything is optimal with her, but the problem is with the significant other. 

Dr. Aumatma: 

They end up wasting time that way. They come back six months later and are like, “We’re still not pregnant.” The guy finally gets tested, and he is like, “Oh, sorry, it was my sperm all along.” It is a little bit of a bummer when that happens. 

We just want to cover all of the bases from the get-go, especially for fertility. They don’t have time on their side. Most of them don’t have patience. Even if it was a 30-year-old, she still wants to be pregnant yesterday. She is not in here, “Four years from now, I’d love to have a baby.” “I started trying, and I should have gotten pregnant last month. It didn’t happen. What the heck?”

Once that decision is made that they want to have a child, that pull is so strong. It’s so anxiety-provoking when it doesn’t happen quickly. Regardless of how old they are, time is not always on their side, just because of how we are as humans. We want everything now. They end up saving time in the future. 

Believe it or not, so frequently, men are the ones who are like, “I was never paid attention to. No one ever talked to me. I was always looked at as the sperm donor. ‘Who cares about you?’” As much resistance as they have coming in, once they start feeling different, then they’re like, “Huh. I didn’t realize it was possible to feel so good. My energy’s better. I sleep better. My sex life is better.” Those are the things that they care about, and those are the tangibles they’ll see improve. Most of them are like, “You changed my life.” It didn’t take a lot. Doesn’t have to be major anomalies or things out of whack. It’s just taking a 7/10 or 8/10 to a 10/10 experience in life.

Studies are coming out that men with optimal levels of testosterone will have lower rates of cancer and longer lifespans because they have optimal testosterone. Similarly, it’s been some of these studies have shown that men that had sperm issues were more likely to have cancer later in life. Men with lower testosterone is on the rise.

When we think about the preventative aspect of this, they are getting what would have been 10-15 years down the line as far as their health decline. We can catch it now and change the trajectory of their whole life. 

Dr. Eric: 

I’m sure that’s very rewarding for you and obviously for them. What are some of the things you do to optimize fertility? When it comes to stress and toxins, do you have people clean up their diet, block out time for stress management, do things to reduce their toxic load? Do you do testing? Look at adrenals, DUTCH testing, or a comprehensive stool test? What are some of the things besides the DNA of the sperm that you do for both partners? 

Dr. Aumatma: 

We have a sequence of tests we like to see in all of our couples. On the female side, we really want a comprehensive overview of how her hormones are functioning in her body. What are the deeper aspects of how her body is responding to stress? This is not just cortisol. 

How is TRH, for example? Thyrotropin-releasing hormone is one of the starting points. It’s a trigger. We have an experience or stress. TRH is the first one on the front lines. We don’t have a way to measure TRH, but we have some indices that we can see on labs. If we extrapolate that data, we have a software program we put it into, and it gives us this deeper aspect of how quickly is this getting on board? Is this over-responding? A lot of cases, it is. A cat jumps in front of you, and your body is responding as if it’s a lion. That’s problematic. 

To be able to see that on some lab values is amazing. Then we can dial back and say, “Oh, we see how your body is actually responding to these stressors,” regardless of if you have that stressor or not. Then we can go in with herbs, homeopathics, a whole host of therapies or modalities that can help to shift how that person actually responds to triggers. 

We want to change it at the deepest level and see that their body is becoming more stress resilient. I feel like most people, when we mention stress, are like, “She’s going to tell me to meditate.” No, actually. If you have time to meditate, go for it. Meditate all the time that you have. What I find is that if we don’t change these underlying things, then regardless of how much you meditate, you’re still going to have a triggered response. 

If we can regulate people’s nervous systems and shift the dynamic that people are having to triggers, how is the body responding? How quickly does that TRH come to the party? Then we really have the ability to create some space before that trigger is creating stress. To me, that stress resilience, that is the first set of tests we are doing.

The second is the hormones. You mentioned the DUTCH test. That’s one of our favorites. We love to see the urinary metabolites. We love to see how the hormones are processing through the body. It’s not just is your body producing a hormone? Also, is it converting it at the right pace? Is it converting it at the right times in your cycle? 

That’s giving us information about how to approach it. Rather than saying, “Hey, you have too much estrogen” based on one snapshot of a test, we can say, “You have too much estrogen only from cycle days 3-12. Let’s regulate that only during that time.” We can get hyper-focused on what needs to be regulated when instead of a willy-nilly, everyone gets DIM or whatever. I hate those one-shot everything approaches because it doesn’t work for everyone. The DUTCH test is really high up there.

The other one we love is the nutrient assay. How are your cells absorbing or utilizing these nutrients in your body? Not just how much magnesium do you have floating around in your bloodstream? That’s a really terrible assessment of magnesium levels. How much is actually going into your cells? Do your cells have enough magnesium to do all of the functions? That is going to be a much more helpful approach to figuring out what is going on there. 

Our last and newest test is the vaginal microbiome. It’s connected to the gut microbiome, so it gives us a little bit of reflection of the gut. But there are so many studies coming out every single day about how much the reproductive microbiome is influencing pregnancy: the ability to get pregnant, stay pregnant, and have a healthy baby at the end of the process. All of it is predictable through the vaginal microbiome. That has become a really essential test for us as well. 

Then we have a bunch of trackers and things like that. We are using CGMs. We are using basal body temperature tracking. We’re using hormone tracking through at-home urine strips. Those are all the ways that we can continue assessing and getting feedback about whether or not the things that we’re doing are actually impacting the outcomes that we want to see. 

On the male side, there is the semen analysis. Also, a comprehensive lab analysis to get a sense of the same things that I talked about on the female. How is stress impacting your body? How much of an impact is it? Are there triggers that shouldn’t be triggers? That kind of stuff will help us get the nuances of what this person is going to need to help shift their bodies out of survival mode and into creation mode. 

Dr. Eric: 

All right. Do you mind mentioning, as far as some of the names of the tests, specifically the nutrient test and the vaginal microbiome test? What companies offer those? 

Dr. Aumatma:

Cell Science Systems is the nutrient assay. The vaginal microbiome is MicroGenDx. These are really only available through practitioners. If there are people asking about this, they may need to work with someone who can actually order the tests for them. 

Dr. Eric: 

Same thing with the DUTCH. It sounds like you do a DUTCH Complete with Cycle Mapping on everybody? 

Dr. Aumatma: 

Yep. 

Dr. Eric: 

It sounds like you don’t do it on men. Obviously not the Cycle Mapping on men. 

Dr. Aumatma: 

No, definitely not. We have a few men who I really would love to see a DUTCH Complete on. It’s not a standard. We don’t test everyone. We can get a lot of information just from the basic tests. 

It becomes a necessity when their testosterone levels are low, and we have worked on it for a little while, and they don’t improve. That is where I start thinking, if we really had a DUTCH test on you, we would be able to see if your body is converting your testosterone into estrogen. Is that why you don’t have estrogen? Or do you have low reserves? You don’t have the building blocks for the testosterone? It would really help narrow and hone in on what is the best approach to support that person to get to that optimal level? 

I’m thinking of a couple of guys right now who have low levels for their age. We have worked with them for a little while. I usually expect to see an improvement within 2-3 months. If I don’t see those levels go up in 2-3 months, I’m starting to think, is there something deeper here? Should we be looking at something else? 

If you have the nutrients that you need to build testosterone, and you have herbs that are driving your body’s awareness that testosterone is needed, then we should see that outcome in a measurable way. If we don’t see it in a measurable way, in a reasonable amount of time, then I truly would like to get to the root of it.

Granted, guys are funny because they will wait on testing. Women are like, “Just tell me! I want to know everything. I want to know everything up front.” Guys are like, “Do I really need that? Will it really help me?” I take it a little bit slower with the guys. Ideally, we would like to get those numbers when we can. 

Dr. Eric: 

Makes sense. Let’s talk thyroid. How common are thyroid imbalances in those who are having problems conceiving? There are a lot of questions I have. What is the optimal TSH during pregnancy? What is the prevalence of thyroid conditions and the impact you think it has on someone conceiving, someone having a healthy pregnancy once they do conceive?  

Dr. Aumatma: 

Totally. Thyroid is a really huge component of fertility. PCOS, which is one of the leading causes of “infertility,” one in two women with PCOS will have infertility. Thyroid is almost always a cofactor in every woman with PCOS. It’s not just that she has this PCOS picture; almost always, her thyroid is not functioning optimally, which is then contributing to the PCOS picture. Often, not enough production of thyroid hormones will cause anovulation, irregular menstrual cycles, and infertility in general for unknown reasons. 

Essentially, thyroid has a direct correlation to fertility. Actually, we don’t know what they do yet, but there are receptors on the ovaries for thyroid hormone. The fact that there are receptors means there is a direct impact. Science hasn’t figured out what it is yet. But that research is happening. Hopefully, we’ll know soon. 

My sense is any time there is a receptor on a specific gland or cell or anything like that, it’s huge. This is going to impact, yes or no, not just this is maybe going to be helpful. It’s a direct impact. 

Thyroid is our metabolic regulator. You guys probably know that. If that regulation isn’t happening, it makes it really hard to sustain the growth of this little human in our bodies. If the thyroid can’t regulate, which we can talk about thyroid and pregnancy, but there is so much dysregulation. Our body is constantly trying to adapt. 

What will happen in pregnancy is—if we are observing thyroid through pregnancy, which if people are working with us, we are—those numbers are changing every single month. The TSH was fine? Now it’s totally not fine. What’s going on? We really have to make sure to monitor thyroid throughout the entire pregnancy.

I have seen a lot of doctors say, “Here’s your dose. See you later. Good luck with your pregnancy.” The reality is our needs are changing in every trimester. Every person is unique. If there is no way to pre-predict what the need is going to be, the only way to know is to make sure that you’re being monitored. That has a really big impact.

The autoimmune aspect of the thyroid is huge. If someone has antibodies to their thyroid, what I’ve seen is that they commonly have recurrent pregnancy loss. That is one of the leading causes or reasons why someone could have recurrent pregnancy loss, which is one of our sub-specialties. We end up seeing a lot of women with these autoimmune thyroid conditions that sometimes are not getting pregnant, but a lot of times, they are getting pregnant relatively easily. But the haywire of the immune system is then impacting the outcome of that pregnancy.

There are a lot of different aspects to how the thyroid is impacting and having a role to play in whether or not someone is going to get pregnant or not, and what the outcome will be. 

Dr. Eric: 

That’s interesting. What you’ve seen is someone with thyroid autoimmunity might not have a problem getting pregnant. I’m sure it depends on the person. Some might have issues. Even if they have no problems getting pregnant, carrying the pregnancy, having the recurrent pregnancy loss is what you see very commonly with thyroid autoimmunity.

I don’t know how many cases of non-autoimmune thyroid you see. If you see someone who has elevated TSH and/or lower thyroid hormone levels, but antibodies are negative, does that make it less likely for them to conceive in the first place? 

Dr. Aumatma: 

The non-autoimmune thyroid people tend to struggle with fertility. The autoimmune thyroid people tend to struggle with recurrent loss. That’s a big generalization. There are always going to be people outside of that generalization. 

In general, the autoimmune component, I think, creates an unhealthy environment for that baby in utero, whereas the sub-optimal thyroid function creates a difficulty in conception. Or we see it show up in other ways. We see it in anovulation. We see it in dysregulation of the menstrual cycle. It’s showing up as direct hormonal fertility issues. But actually thyroid is playing a huge role in dysregulating those hormones. 

Dr. Eric: 

I imagine most of the cases are hypothyroidism/Hashimoto’s. Do you have any experience seeing people with Graves’ or hyperthyroidism at all? 

Dr. Aumatma: 

I would say Graves’ is probably not high on the list of people that we see. We have had a handful of cases where Graves’ was present, and they didn’t know it. A lot of times, people know that they have Graves’. In that case, I’ll just be like, “I might not be the right person for you.” 

If they didn’t know that they had Graves’, but we see it in their antibodies, we see it in their TSH and T3 and T4, then we certainly will make an attempt to try and help them. We are not always successful. But we are successful some of the time.

Hashimoto’s and hypothyroid, all the time. That’s the more common situation. We see it a lot. 

I also feel like even though Hashimoto’s and Graves’ get put together as autoimmune thyroid disease, Graves’ is certainly way more complex. Someone like you who is hyperspecialized in that is a better fit for someone who has Graves’. 

Hashimoto’s, to me, falls more under things that we can do a lot about, especially if they are dealing with fertility issues. If they’re not, they should go to you regardless. If they have thyroid issues and are dealing with not fertility, go to Dr. Eric. 

Dr. Eric: 

Thank you. When it comes to the antibodies, someone with Hashimoto’s, because they have Hashimoto’s, that recurrent pregnancy loss is common. You will do things to improve their immune system health, I imagine. Do they absolutely need to have negative antibodies when it comes to TPO or antithyroid globulin antibodies? Is that your goal? Get them negative, or get them as low as they can before they start conceiving? 

Dr. Aumatma: 

Yeah, it’s multi-layered. I have seen cases in which we start out with antibodies at 800. Crazy high antibodies. I have talked to other thyroid experts who are like, “Oh no, the number doesn’t really matter. If you have any level of antibodies, you have antibodies, period.” 

Whereas to me, I’m like, the amount of antibodies makes a difference. If we go from 800 to 25 or 40, that’s going to be a significant difference in how much your immune system is responding and contributing to the dysfunction. Yes, my goal is let’s get them as low as we can possibly get them.

The other factor, however, is when people have those minor elevations in antibodies, sometimes they don’t go away. But we have addressed the root cause of why they had the antibodies to begin with. Their symptoms go away even if there is no change in the actual number of antibodies. In that case, we say, “It’s okay that your antibodies didn’t go from 40 to 0. But we addressed the root cause. We have healed a lot of what was happening under the surface. You’re no longer having the reactions and symptoms that you’re having. Your fertility hormones have optimized. At this point, we think it’s okay and safe for you to go ahead and get pregnant, and we’re going to keep managing the antibodies as well as your thyroid through pregnancy.”

Mostly, it’s just a time factor, I think. If we had more time, then we would wait until their antibodies were totally zero. A lot of these women are 35+. A) They don’t have the patience, and B) We are like, “How long is it okay to wait before your fertility really does take a turn?” We don’t always know the answer to that. We are looking at 3-6-month periods where we have focused time with someone before we have to be like, “They have waited long enough. Now they need to go and start trying.” 

In those cases, there are things like LDN that are great to support the antibody autoimmune picture while they’re pregnant and sustain it through pregnancy. They do relatively well and have healthy pregnancies. Their thyroid is managed, which is not always the ideal, I understand. But we do the best in that case, so they can quickly go to pregnancy.

Dr. Eric: 

You do have some people on LDN during pregnancy if you have difficulty getting those antibodies where you want them to be. 

Dr. Aumatma: 

Yeah. LDN is considered very safe in pregnancy. It’s a good tool if we absolutely need to use it. It’s not my go-to. it’s not the first thing that I want to be doing with people. But if we worked on the underlying factors, we worked on the things that we know to work on, and their antibodies are still high, absolutely. LDN will save the day all day long. 

Dr. Eric: 

How frequently do you recommend retesting the thyroid panel as well as antibodies during pregnancy? 

Dr. Aumatma: 

If they started with thyroid issues pre-pregnancy, then every 4-6 weeks. If they didn’t, then 8-10 weeks. They can go a little bit longer in between tests if they have no thyroid issues. 

Like I said earlier, the number of women that I see have dysregulated thyroid through pregnancy is really high. If we are supporting and are on the team of pregnancy support for people, then we always want to see the thyroid. We will see plenty of women who are like, “Hey, I didn’t have any thyroid issues. What the heck, Doc?” Pregnancy will sometimes bring the need for support for the thyroid up way more.

The other piece that we didn’t talk about is often pregnancy is stimulating antibodies. I haven’t seen it as much during pregnancy, but there will be a rise in autoimmune thyroid conditions post-partum. 

A lot of those women will struggle with the second baby. First baby, they’re fine. They got pregnant, no problem. They had a healthy pregnancy. Gave birth to a healthy child. Then baby #2, they’re like, “We have been trying for three years, and it’s still not happening. What’s going on?” 

Oftentimes, they have got a thyroid autoimmune condition that popped up post-partum because the pregnancy is a hard thing to metabolically regulate. It’s a really high demand on our body. It’s not a surprise that our body would wig out after a pregnancy. It’s a lot of change, a lot of hormonal flux, a lot of nutrients being pulled that all of a sudden, what your body was able to do before you had any children is completely different from what it’s able to do now. It doesn’t have enough of the reservoirs to be able to do that. 

Dr. Eric: 

A lot of these women with post-partum thyroiditis, if you were to test the thyroid antibodies during pregnancy, they would come back positive. The problem is with conventional medicine, if the TSH is within the reference range, if it’s a 3.5, which is in the lab reference range, they probably won’t test the antibodies. If they did, they would most likely see that those antibodies were elevated. 

When they give birth, it’s almost like the straw that broke the camel’s back rather than the trigger. They had this autoimmune component, and it perpetuates sometimes after that, is what you’re describing, making future pregnancies difficult. 

Dr. Aumatma: 

It’s also absolutely what you said about the TSH not being abnormal enough to trigger the antibodies. I have seen so many people who try to go through the insurance route who will have struggle with getting their doctors to order antibodies. “Nope, they’re fine. Why would you test those? Your TSH is fine.” 

We didn’t talk about optimal levels of TSH, T3, and T4 in that fertility period. To me, I think it’s slightly different than what is normal. I like to see TSH pre-pregnancy below 2, for sure, ideally even below 1.5. I should put a cap on that. Above 1. Between 1-1.5, which is a really narrow range. 

T3 and T4 ideally somewhere in the middle of normal is good, optimal. 

For pregnancy, the ACOG organization has put TSH below 2.5 as the optimal. We will generally go with that. If they were below 2 pre-pregnancy, and it goes up to 2.5, we’re not freaking out. But TSH in pregnancy is also very important for the development of the baby. 

If we don’t have optimal T4 during pregnancy- T4 is the hormone that crosses the placental barrier and impacts the brain development specifically of the baby. If we don’t have optimal TSH or optimal T4, then the health of the baby is at risk. We definitely care about that. That’s a significant factor. 

Also, a lot of times, women have fine TSH, fine T4 but are struggling with T3. They feel like shit through pregnancy. We could give you a tiny little snap of T3, and you would feel so much better. They go to their doctor, and their doctor says, “Absolutely not. You don’t need T3. You’re fine.” 

The health of the mom matters. How she is going through this pregnancy matters. It’s really important for her not to feel exhausted the entire pregnancy. It could be avoided with microdoses of T3, which are not going to cross the placenta but are going to make a difference in how she feels. 

It’s a lot of things to weigh out. For me, I’m like Mom first. Yes, we absolutely care about the baby’s health. We care about what is happening for the baby. We care about pregnancy and post-partum. But we also want to support this mom as she is going through this journey. It’s not just about the baby. 

It’s really not fair to moms who are just the carrier of the child. “Grow this human. We just care about this human who will come out of you,” which is the attitude of a lot of doctors. We want to be the advocate for the women. You can have a different experience. If you’re exhausted, and your thyroid hormones are suboptimal, but they’re meeting the status quo, your body’s need is still a little bit higher than the status quo. Supporting that will help you so much. 

Dr. Eric: 

Sometimes, you do go by symptoms regardless of what the thyroid panel says, or if someone is a little bit on the higher end but still within the lab range, you might recommend thyroid hormone or some T3. Is desiccated thyroid hormone safe during pregnancy? 

Dr. Aumatma: 

I don’t like it. It’s adding dysregulation amongst dysregulation, right? Pregnancy is this time of massive flux. The need is going up and down. Then you add another variable, which is desiccated thyroid, which is also not consistent. It’s really hard to regulate. My ideal would be microdoses of T3, which is just going to push it a little bit but not so much that it’s going to replace or be overwhelming to her body. 

I feel safer with that. I need to look into the studies. Is desiccated even safe? I don’t know if it’s contraindicated. I will look that up. I never use it. Oh god, that sounds so scary to me, to add another layer of dysregulation there. 

Dr. Eric: 

One last question I have is when it comes to supplements. I know you have your own supplement line. I’m guessing you don’t just recommend a prenatal. You probably do recommend a prenatal, but in addition to that, do you recommend Omega-3 fatty acids? Based on the nutrient testing you do. Some of it depends on what comes out on the test results. 

Dr. Aumatma: 

There is a standard for pregnancy, which is a prenatal, Omega, or DHEA, and a good vaginal and gut probiotic. Those are the foundations. 

On top of which we could tailor to whatever people need. Those can really start in the fertility period or preconception phase. The fertility line of supplements is really to dial in what do people actually need based on what’s happening for them? Infertility is often a blanket diagnosis. “You have infertility.” It means absolutely nothing for the majority of people. 

Instead, our supplements. The first thing will be you don’t just go online and take a bunch of random supplements. Totally anti-that. If you land on our website, it will take you through a quiz that will point you into the direction of which is going to be the right supplement to layer on top of the core supplements that you’re taking. 

Our approach is very different in the fertility space. Instead of every supplement under the sun, every nutrient under the sun, if we could figure out that your issue is with the uterine lining, for example, let’s just give you the things that are needed to support the uterine lining instead of every single nutrient that is going to overwhelm your body, make really expensive pee and poop, but do nothing actually to support your fertility. 

Essentially, how do we tailor this to each person rather than how do we make blanket recommendations? That’s the foundation. If they’re working with us, then of course, the custom nutrients and things that their body specifically needs can be tailored even more than our analysis. It’s called a Smart Fertility Analysis.

By the way, I should say that since you mentioned the supplements. We just rebranded. It’s coming out really soon. The new line is going to be called Madre Fertility. It has the analysis on the website. If someone looks up Fertile Foundations, they will still find my line, but it doesn’t have the fancy analysis guiding them into what they should take.

Dr. Eric: 

That sounds awesome. Very cool. Congratulations on the rebranding of the supplement line. 

I know you covered a lot. Is there anything else that you wanted to share? Anything else I didn’t ask you that I should have asked you? 

Dr. Aumatma: 

No, I think this was really good. There is a lot of good questions in there. 

Dr. Eric: 

Thank you so much. Dr. Aumatma, where can people find out more about you? If you could let them know about your website, your podcast, anywhere else, like social media. 

Dr. Aumatma: 

Sure. The podcast is called Egg Meets Sperm. That’s a really good starting point if you want to learn more about fertility, how to navigate stuff. 

Our website is HolisticFertilityInstitute.com. Social media, I’m @HolisticFertilityDoctor on any platform. 

Dr. Eric: 

I appreciate your taking the time to share this with everyone. 

Dr. Aumatma: 

Thank you so much for having me, Dr. Eric.

 

Recently, I interviewed Dr. Jolene Brighten, and we talked why it’s crucial to understand what’s normal for your menstrual cycle, how thyroid health impacts your fertility and sexual desire, myths about low libido and aging, the role of the vaginal microbiome, her flexible 28-day plan, and more. If you would prefer to listen to the interview you can access it by Clicking Here.

Dr. Eric Osansky: 

I am super excited to chat with today’s guest. We have Dr. Jolene Brighten. We are going to be talking about sex, hormones, periods, tying some of it into thyroid health. Let me go ahead and dive into Dr. Jolene’s impressive bio here. 

Dr. Jolene Brighten is a hormone expert, nutrition scientist, and thought leader in women’s medicine. She is board-certified in naturopathic endocrinology and trained in clinical sexology. Dr. Brighten is the author of Is This Normal, a non-judgmental guide to creating hormone balance, eliminating unwanted symptoms, and building the sexual desire you crave. 

A fierce patient advocate and completely dedicated to uncovering the root cause of hormonal imbalances, Dr. Brighten empowers women worldwide to take control of their health and their hormones through her website and social media channels. Dr. Brighten is an international speaker, clinical educator, and medical advisor within the tech community. Thank you so much for joining us, Dr. Jolene. 

Dr. Jolene Brighten: 

Absolutely. I’m so glad to be here with you and everyone who’s listening right now. 

Dr. Eric: 

We were chatting a little bit before I started recording this. I was telling you how I was listening to your audiobook. Really enjoyed it. 

I also let you know how my wife was not freaked out, but she was surprised because you don’t hold back in the book. You talk about sex, orgasms. We’ll talk about some of that here. Very necessary book. 

What motivated you to write the book, Is This Normal? You had written another book prior to this, The Pill Book, which was also amazing. If you could dive into that background. 

Dr. Jolene: 

Is This Normal? was born out of all of the questions I receive. So many people not understanding their body, having received misinformation. We know social media is full of it when it comes to women’s bodies. Everyone is asking, “Is this normal?” There was that inspiration. That is how we arrived at the title. 

When I look back at where this really came from, and what it was rooted in, firstly, women know their bodies. They know they’re normal. However, they haven’t been given all of the information. In fact, they’ve been given a lot of misinformation. 

When you look at the states in the United States, most of them are not teaching medically accurate sex ed. At the same time, we’re being told a lot of things like, “Period pain is normal. Being tired is normal.” I’m sure you have a lot of people who have heard that, especially when it comes to thyroid disease, or the myriad of things that affect women. They are chocked up as being “normal.” When women say, “I know my body. This isn’t normal,” they’re often pushed back on.

I wanted to help answer the question of what’s normal, what’s not when it comes to our anatomy, our hormones, our sex life. Then also help people navigate finding their normal. As anybody who has taken a statistics class knows, normal exists within a bell-shaped curve. Right smack dab in the middle is where a lot of people are hanging out. Then you have the outliers underneath. You have the distribution of normal. Normal is a gradient. Even when you get outside of that bell curve, you will find that people are still normal. It might just be their normal.

I help people navigate all of that and set it up as the book. If you were handed this from the day you got your period, you would be less likely to experience medical gaslighting. You are less likely to struggle with your hormones. You are certainly more likely to experience the pleasure that you’re after in this life. 

Dr. Eric: 

Everybody’s normal is different. You also mention in the book that people mistake common for normal. Just because something is common doesn’t mean it’s normal. People ask me all the time as well. Maybe not in relation to sex and orgasms. Sometimes, their hormones. For so many different things, is this normal? I’ll often say the same thing, “It’s common, but it doesn’t mean it’s normal.” You expanded on that. Maybe it’s someone’s normal but not necessarily normal for everyone. 

Dr. Jolene: 

As you bring that up, I think right away about how period pain is chocked up to be normal. It’s not normal. Period pain is not normal. It is common. I have been saying this for well over a decade. If you scroll my Instagram, you will see that. I was popping off about that so long ago. 

People have really challenged me. Doctors have challenged me. “If it’s not normal, why do so many women have period pain?” I’m like, “You’re a doctor. Why don’t you look it up?” What is going on is such a disservice to your patients.

We do a big disservice in medicine when we mistake that what we see are sick people. Who comes to us? People who have problems. People who want problems fixed. We mistake our experience of constantly seeing that everybody has period pain as being something that must be normal because everybody has it. You have a bias in that. 

In fact, we know from the research that because of this bias, because of the bias that exists in medicine that is against women and puts them at a disadvantage, something like period pain or pain with sex, which gets dismissed or chocked up as normal, is a big reason why it’s estimated for the condition of endometriosis that 6/10 never get the diagnosis. In fact, it can go as far as 11 years for somebody to actually get the diagnosis. This is a condition that affects anywhere from 10-15% of women.

I bring this up because I think it’s important to understand that sometimes, people are like, “Oh, what’s the big deal? Why should we even care about this?” This happens way too much in women’s medicine. 

In the case of endometriosis, this one example, a leading cause of infertility, something that can lead to gastrointestinal issues, problems that evolve with the bladder. Having actual lesions. Endometriosis is when tissues that are similar to the lining of your uterus but not exact exist outside of your uterus, and they respond to estrogen. It is deemed an estrogen-dominant condition because estrogen will stimulate the tissues to grow. Just like the lining of your uterus, they will bleed when you menstruate. Because of that, you can end up with strictures, tightening of tissues, lesions that are very painful, and lots of inflammation. That can affect your ability to have a bowel movement every day.

Dr. Eric: 

You said on average, with endometriosis, it can take how long to get diagnosed? Up to 10 years or longer? 

Dr. Jolene: 

Yes. It can take up to 11 years. When you consider the research says that only 6/10 women are actually getting the diagnosis, then you consider that those six may have had to go 11 years of going to their doctor, saying, “I have period pain. I have pain with sex. I have pain with urination. I have pain with my bowel movements. I have extreme bloating occurring around my period.” 

This is something you’ll see a lot on the internet. I don’t know if you’ve seen this meme going around. Women are like, “Oh, all the hot girls have bloating.” I look at that as a practitioner. Wait, if you have bloating, and it’s that significant- Some of these women are showing pictures of 4-6 months pregnant-looking bellies. That’s how bloated they’re becoming. 

When you consider that, I’m like, “Hold up. This could be endometriosis,” especially considering how long it takes to get the diagnosis, how misunderstood it is, and how many doctors are really dismissive of these things. As you know, working your patient population, if we see extreme bloating like that, that could also be SIBO, something causing inflammation in the intestines, related to thyroid disease and slow motility. In anybody who says, “All hot girls bloat,” I’m like, “Pause. Back it up.” That’s not normal. 

Dr. Eric: 

I’m glad you mentioned that. You’re not saying endometriosis is the cause of all bleeding. Same thing with period pain. If a woman has period pain, it doesn’t necessarily mean they have endometriosis, just that it’s commonly overlooked and missed. Many doctors might say that period pain is normal, and maybe it is, or maybe it’s not related to endometriosis. The point is, they just dismiss it. They tell their patients that it’s normal. Maybe the same goes with bloating and some of these other symptoms. 

Sticking with the topic of PMS and period pain. Some women have heavy menstrual flow. This is when we get into common versus normal. A lot of women do have some pain and cramping. Some have a heavier flow. In a perfect world, would you say there would be no period pain and a regular flow? Or is it some women’s normal to have a heavier flow and some cramping, for example? 

Dr. Jolene: 

The question is what is the flow? What are we talking about here? Let’s break down what a normal period should look like. Firstly, having some mild cramping, totally normal. Feeling a bit tired before your period, also normal. Feeling like you’re totally wiped out, exhausted, never should be considered normal. 

If you are driven to have to take NSAIDs consistently, every single period, for multiple days on your period, that’s not normal. Sometimes, people will push back and say, “Everybody’s pain tolerance is different.” It doesn’t matter. Your pain tolerance, whether it’s different than anyone else, doesn’t matter. 

If your period interferes with your activity of daily living, it causes you to vomit, to cry, you’re having extreme diarrhea with it, these are signs that your prostaglandins can be really elevated. Prostaglandins are hormone-like chemicals that stimulate the uterus to contract. Very good thing until there is too many of them, or they’re super potent. 

They also can be part of the inflammatory picture that we see with what people classify as “period flu.” Period flu is feeling really achy, like you’re getting sick, very fatigued before your period. That’s not normal either. 

I have more to say about the period. Just to jump in real quick, Omega-3 fatty acids in the diet and contributing magnesium are two things you can do to mitigate those prostaglandins and make an easy period. I typically recommend that you start with diet first. As you know, eating cold water fish consistently throughout the week, getting enough magnesium-rich foods, that can be a struggle for some people. 

Looking at something like 1,500-2,000mg of Omega-3 fatty acids, you actually make prostaglandins from Omega-3 fatty acids. That’s why those are so important. Anywhere from 150-300mg of magnesium. I like glycinate best. That helps women sleep as well. That can be really helpful to bring in and mitigate some of that pain. I wanted to give those solutions before I go further with the period talk. 

With the period, the average cycle is going to fall 3-5 days. If it’s less than two days, that’s pointing to too little estrogen. We can see that in late-stage perimenopause. Late-stage perimenopause is right before you move into menopause. Totally normal for periods to go all over the place, but also to have those shorter periods. 

If you are younger than 45, before we say it could be perimenopause, could it be anything else going on? Is there anything we can do to help with that? 

If your period is going beyond seven days, that is problematic. We get worried about that. That’s too heavy of a period. Maybe estrogen is stimulating the endometrium too much. Maybe you have fibroids. Maybe you have adenomyosis, which is a cousin of endometriosis. You can see clots accompanying the menstrual cycle when you have adenomyosis. I will say that condition is missed even more than endometriosis. 

I talk about a lot of conditions that are missed in the book, in order to help women advocate for themselves and have a more productive conversation with their doctor.

Now, in terms of the flow, how heavy should it be? Here’s what’s normal, and not always talked about. Firstly, a period that starts and then stops, that’s normal. Maybe your period, “Oh, I’m starting to have a flow for several days.” Then it’s really tapered off. Then it makes an appearance the next day. That’s not necessarily abnormal. 

Having a period flow that is so heavy that you need a super tampon and a pad, or you’re changing a tampon or a pad every single hour. I’m not talking about a tampon on a light day. I’m talking about a tampon and a pad because the flow is so heavy, it’s the only way to contain it. If you’re changing one of those products every hour, if you have to wake up in the middle of the night because the flow is so heavy that you have to change those products, this is too heavy.

I have billions of checklists in the book. I have a little checklist on what is not normal for your period versus what is normal. It’s important to understand what these parameters are. 

Like I said, your period might be three days up to six days. That’s all considered normal. When we have these outliers, we need to investigate what’s going on. We have talked about period pain. We have talked about the period itself. I’d like to talk about cycling. Are you good with that? 

Dr. Eric: 

Yes, definitely. 

Dr. Jolene: 

Cool. This is another one people are confused about. “My period has always come 24 days. Isn’t a 28-day cycle the norm?” Very few people are having a predictable 28-day cycle regularly. We set it up as a way to teach about the menstrual cycle. There is some science to support there is these averages of how long the luteal phase it can last, and how long it should last, and when ovulation might happen.

The myth of the 28-day cycle has lent itself to the myth of everybody ovulates on day 14. None of that is true. You may even ovulate one month on day 13 and the next month on day 15. It shouldn’t be that you ovulate one month on day 10 and the next month on day 28. 

Your cycle shouldn’t be something that is less than 21 days or greater than 35 days. Even though I say that, if you consistently have had a 38-day cycle your entire life, and you’ve been worked up and nothing’s going on, then that is your normal. 

In medicine, if you’re going beyond 35 days, we need to investigate things like polycystic ovarian syndrome (PCOS). There are other conditions as well, but PCOS is far more common than those. 

If your cycle length suddenly changes, we need to look at if this could be hypothyroidism. Changes in the menstrual cycle are one of the most missed symptoms when it comes to hypothyroidism in my experience. That is because clinicians are trained to put someone on the pill when the cycles become irregular rather than test and understand what’s going on, unless, the caveat being, you want to have a baby. Then you might get that thyroid panel. 

When it comes to the cycle length, that should be pretty predictable within a few days of itself. It’s not abnormal if you did have 27 days and then 29 days. But it is abnormal if there is a change within your normal, or you are less than 21 or greater than 35. If you never know when your cycle’s showing up, you definitely need to see a provider.

Dr. Eric: 

I should say I see a lot of people with hyperthyroidism as well, which can also impact the cycle. In different ways, too. I can’t see there is a consistent pattern. Some people will completely stop cycling for a few months. Sometimes, it might be more frequent. Regardless of whether someone has hyper or hypo, it could impact. Like you said, especially in the case of hypothyroidism, often it’s missed. Doctors will look at other things. 

Dr. Jolene: 

Totally. I see the same thing with any thyroid disease. Sometimes, the cycle stops. Sometimes, it becomes irregular. Sometimes, the periods become very long. That is something that should always be ruled out. 

Most people are not aware of this. You may be, but I definitely want your audience to understand that when it comes to follicular development, this is how we get a mature egg that we then ovulate. That is very dependent on the thyroid hormones being optimized. If you want to have a baby, absolutely crucial. If you don’t want to have a baby, absolutely crucial because only by ovulation do we get the progesterone levels that we need.

You have been in the thyroid space for a long time. Most doctors will just check a free T4. Then you get to functional medicine. We are looking at free T3. We have those patients who just do better on natural desiccated thyroid hormone, which we know also contains T2. I have always said the body doesn’t do something for nothing. If it’s still making these hormones, there is a reason. 

What’s interesting is when you look at the research, T2 is actually involved in that follicular development and interaction with the mitochondria, which are really tending to the health, the quality of the eggs, and the health of the ovary overall. Thyroid health directly impacts ovarian health. This is so crucial not just for pregnancy but in the longevity conversation. 

The longer we can have our own natural hormones taking care of us, the less risk we have for things like dementia, cardiovascular disease, osteoporosis, type 2 diabetes. I could keep going. Take care of your thyroid, your mitochondria. That is one key to taking care of your ovaries. 

Dr. Eric: 

Based on what you just said, if someone is taking levothyroxine, synthetic T4, and if they are having fertility issues, not to say it’s definitely related to that, but it could be. When they are taking T4, they are obviously missing out on the T2. They are hoping that will convert to T3.

Dr. Jolene: 

The hope, right? Will it convert? Unless you’re post-thyroidectomy, which means your thyroid has been removed, your thyroid will still make some T2. It will putt along. It will do that. What we do understand really well from the research is that T4 is absolutely crucial, not just in follicular development in that egg health, but also preventing miscarriage. 

The long-term studies that have looked at when Mom had insufficient T4 showed that even these children, they followed this cohort up to 16 years of age, and they were behind in terms of cognition and motor skills. We know it has a tremendous impact on fetal growth and development. 

For anyone listening, if you’re like, “Why is my doctor giving me T4?” T4 crosses the placenta. There is this magic thing that happens in medicine where as soon as you become pregnant, you become the thing that’s carrying the baby in the way of the baby, and everyone is focused on the baby. They forget your health and wellbeing matter as well. 

I say that backhandedly. We know there are great providers out there. But we also know that the United States, we’re at the bottom. We rank bottom when it comes to maternal/fetal outcomes, when it comes to obstetric violence. We win at that. We’re not doing well as a developed nation. 

I want people to understand that if you have a great provider, yay. Celebrate it. Maybe share it in the comments. That would be really great. If you don’t have a great provider, and you feel like it’s just you, it is not just you.

Back to your point. I want to say something that’s been very interesting that I have observed and used in my clinical experience. Women who aren’t necessarily presenting with hypothyroidism, but they are going through IVF, sometimes giving a very low dose, like 25mcg of levothyroxine, can actually improve the outcomes of IVF. Do I have great studies that I can tell you about that? No. 

When we see things like that free T4, it’s hanging around 1, sometimes it drops below 1. Ideally, we want that 1.2, 1.4. That is somewhere where it’s like let’s just try. We’re only going to do it for one cycle. It will only be a few weeks to support you. You’re not going to have hyperthyroid symptoms from that. I have seen some pretty good outcomes. Take that clinical pearl, people, for what it’s worth, and discuss it with your provider.

Dr. Eric: 

That was awesome information. Low sex drive, low libido, something else that maybe practitioners in general, maybe not functional medicine practitioners but medical practitioners, would say is normal and more common. Why is that so common? What are some of the underlying causes? 

Dr. Jolene: 

Hypothyroidism and hyperthyroidism. Oh man, the way your nerves are so grated in hyperthyroidism. Good luck getting in the mood. That can be really hard.

To answer your question. Why is it that so many women go to their provider and say, “I’m struggling with low libido,” and their provider is like, “Well, you were born with ovaries. That’s just normal?” I break this down. 

If we go back and look at the history of medicine, the history of medicine has essentially said we have this male component. That is the standard. That is perfection. We will measure everything against this. This other inferior model over here with baby-making accessories, that one should match, right? Everything is through the lens of men. 

With that lens, the myth, and I say this is a myth because I think it’s unfair pressure that society puts on men, is that men are always in the mood. Men always want sex. Men have more testosterone than they are using at a cellular level; therefore, testosterone is the key hormone driving it. Men are always in the mood. 

What we understand, firstly, is that for women, it’s not just testosterone. There is the estrogen component as well that’s really important in terms of your desire, your ability to self-lubricate. At the same time, all the other hormones matter as well, along with stress hormones. 

The stress hormone picture that I’m talking about, and thyroid, and insulin, this applies to all bodies. Doesn’t matter if it’s ovaries or testes. All bodies are affected by these hormones. It can affect their desire.

Now, when we look at the research, and we look at psychologically, are there these differences going on? What we understand is that there are more women who will identify with what’s called responsive desire. That’s where you talk about how you have to get things going to get things going. You’re not in the mood for sex until you’ve actually started foreplay. That is normal. It’s called responsive desire. Both men and women experience that. 

Then we have spontaneous desire, which is what the media shows us that all men should be like. They’re always wanting sex. Sex is always on the brain. They’re always chasing tail, so to speak. 

In reality, that spontaneous desire isn’t something that every man experiences, and women do experience it. When women experience it, they’re often told things like, “Oh, you have the sex drive of a teenage boy. You are more like a man.” Really, when you stand back, this is just a misframing and misunderstanding that men are supposed to be one way, and women are supposed to be another way. It’s absolutely not true. 

I talk about in the book the clitoral conspiracy. Everybody’s heard, “The clitoris was discovered in the 1990s.” Lies. No, it wasn’t. It was discovered a very long time ago. In French, the translation is “shameful member.” What does that tell you right there? It was something to be shameful of. 

They cut it out of anatomy textbooks. Even to this day, the majority of medical anatomy textbooks—this means the books your doctor is learning from—do not have medically accurate illustrations of the clitoris, which is why in Is this Normal? you will find three. I put three in there. If nothing else, y’all are going to know more than what your doctor knows about the clitoris. 

So far, I’ve talked about: We have the component of the different ways that sexual desire can work: responsive and spontaneous. The idea that women have to be different, and if it’s a problem, it has to be testosterone. We don’t know about the clitoris. A lot of people don’t. My necklace, which you can’t see behind the mic, actually says “Cliterate.” It’s a term that Dan Kearn coined to talk about being actually literate about the clitoris. 

Then we have a whole other component called the dual control model, which is all about things that turn us on, things that turn us off. this was research done by Bancroft and Janssen to understand men. 

If everybody is listening, “Well, she’s in women’s health. Why is she talking about men?” I think it’s so important to understand that these experiences are universal. There is a lot of similarity although I did tell you with hormones, it can be different with women. I will talk about that a little bit more.

The similarity being that our nervous system has to be ready and tuned to accept the sexual inputs. Those are the accelerators. If we have too many brake pedals on, those are things like stressing about our body image, stressing about unintended pregnancy, stressing about our relationship. A lot of stress is what you’re hearing. That is going to basically create a nervous system chaos in which you cannot receive the signals that maybe your partner is trying to throw your way. In those instances, it’s also another time to feel like, “Why am I out of the mood?”

When I talk about stress, and I talk about women, I want people to understand that the female body is more attuned to the stressors of the environment because biologically speaking, whether or not you want a baby, whether or not you can have a baby, the tissues, the cells, everything about your being is set up to survey whether it’s safe or not to have a baby. 

Let’s just face it. Babies are noisy. They will give you away if you are hiding from a predator. That’s like my biggest fear. What if there is a zombie apocalypse, and I have a baby? Or I’m pregnant? How am I going to outrun a zombie? I don’t know how I’m going to do that. That’s way out there. But if it’s a different kind of predator, like the real kind, like a tiger, how will you do that? The body knows. The body is inherently wise.

Your doctor says, “Eat right and exercise. You just need to eat less and move more.” You’re doing that. Now you’re never in the mood. That’s a negative input on the system. You just told your body, “The environment isn’t safe. You don’t have enough food.” These different types of stressors will cause biological shifts, shifts in our hormones that can impact our sexual desire, which is our ability to get in the mood. The safest way to live your life in moments that are high stress is to protect you from not becoming pregnant, which means you have no interest in having sex. Does that all make sense? 

Dr. Eric: 

Yeah, definitely. In functional medicine, they talk about the pregneninolone steal, the cortisol steal, where the body is prioritizing cortisol production at the expense of DHEA and the sex hormones. Is that what you’re talking about? 

Dr. Jolene: 

I’m so glad you brought that up. Pregneninolone steal is an outdated way to think about it. I’m not shaming you or scolding you for saying that. If you ever learned about it back when we learned about it, that’s how we talked about it. it’s this idea that pregneninolone, the mama hormone, she has given birth to cortisol and progesterone. In that moment, she is like, “I have to birth more cortisol. Forget the progesterone.” There is nothing left over. 

Now that we have more research understanding the mitochondria and how this is all working, what’s actually happening is the master orchestrator of hormones, your pituitary gland, your HPA of wherever it goes, whether it’s the adrenal axis, the ovarian axis, the ovarian-adrenal-thyroid axis, that is orchestrating things to say, “Let’s get cortisol up. Let’s make sure we are dampening down progesterone.” 

In the book, I have a whole diagram of how stress affects you. Too often as doctors, we say, “You need to work on your stress.” You know in functional medicine, we don’t do it like that. But the average provider that the woman is experiencing, she may go in, and they’re going to say, “You just need to get a handle on your stress.” What does that mean? What does it do? 

As stress goes up, we know cortisol production goes up, and ovarian function goes down. It’s not just progesterone, but all of the cycle can be impacted. Extreme stress, like hypothalamic amenorrhea, we see that you will lose your period. You are not getting enough calories; you are overexercising. 

Anyone who has ever had a significant life stressor, like your dog dies, someone close to you passes away, maybe you were in a car accident, and you miss your period, that’s actually normal. Your body was like, “Hold up.” Survival will come before procreation. Your body is shifting in a way to protect you. 

That’s what I think functional medicine does a lot differently. We stand back and ask why. Why would your body choose to take this path? Rather than trying to strongarm the body into submission, “Body, you’re misbehaving. I’m going to give you a medication. Going to suppress that. Going to do these things.” 

Listen, sometimes we need medications. However, even when we need a medication, we still need to ask why. Why did the dysfunction develop? I say “dysfunction” as in if you are not menstruating, therefore not ovulating regularly, and you should be, something has become dysfunctional in the system. The adaptation, which is meant to keep you alive, has adapted too far. You’ve adapted too close to the sun. You’re burning up. What is happening here? We have to ask the question: Why did this happen? Why did this shift happen? And work at that level. 

Dr. Eric: 

All of this is really fascinating. I want to talk about orgasms. I am 100% sure I have not spoken about this on the podcast. 

Dr. Jolene: 

Everyone wants to talk about orgasms. 

Dr. Eric: 

Exactly. Obviously, there will be overlap. For many people, thyroid health will play a role. Stress hormones, like cortisol. There is also going to be some psychological aspects as well. Let’s talk more about orgasms. 

Before we get into orgasms, if this is going to take long, we can skip over this. Every now and then, there will be someone who has a heightened libido. What would be the cause of having too high of a libido? 

Dr. Jolene: 

There’s no such thing as too high of a libido. That is your normal. When we say someone’s libido is too high, what we are really saying is they have spontaneous desire. That is the mode they are activated on and in which they are going through life. That is completely normal.

We get into trouble when we start pathologizing what is normal. That is definitely one of those instances where people are like, “Your sex drive is just too high.”

The other thing that happens sometimes in those situations is that person’s default of when they are stressed is actually to have desire. That’s not as common, to be in the mood when you’re stressed. But I think those people’s biology are really hip to the fact that the orgasm that we are going to talk about is going to release oxytocin, which combats cortisol’s negative effects. 

Cortisol will not only age you in what you can see, but cortisol will age you at the cellular level. If you are exposed to chronic stress, we know the brain suffers significantly. You can have memory deficits, cognitive deficits. With that, orgasms can actually help. 

This is what everybody gets when they’re intimate. These people will also get the connection. The connection, that intimacy, that act of mindfulness, which if you want to have an orgasm, it is an act of mindfulness. You have to be present in your body to even arrive there. Those things, we know help stress. If it was outside of sex, it would help stress. 

Sometimes, that is also where people are like, “Something’s wrong with you because you want to have sex when you’re stressed.” It’s because something about their being knows, “I can check so many boxes with this that are going to help me drop my stress and optimize my hormones.” 

Dr. Eric: 

A question I have with orgasms then: I’m in my 50s, even beyond that, 60s, 70s. You’re going to have natural decreases in hormones. Can someone in their 70s, 80s expect to have orgasms like they would in their 20s and 30s or even people in their 50s? Should they expect a decline, where maybe they can still orgasm as they get older, but it’s more challenging? Is it just because of what we’ve been discussing as far as the older people get, they’re more likely to have some of these other health issues develop? Some people have them for years, like Hashimoto’s can be undiagnosed for 10-15 years. I’ll stop rambling and have you talk about orgasms. 

Dr. Jolene: 

When I tell you how rampant STIs are in nursing homes, that’s all I gotta say. No, you shouldn’t be losing your ability to orgasm because you are aging. 

As you brought up, with the case of Hashimoto’s, and hyperthyroidism, long periods of undiagnosis that are going to affect the cardiovascular system. Anything that negatively impacts the cardiovascular system or our blood glucose, blood sugar, and our insulin levels, that can impact your ability to orgasm. 

Now, as we get older, we are at higher risk of developing diabetes and having circulatory issues. When we look back at the research, most of it has been done on men. Shocker, I know. If a man can’t have an erection, it’s like, stop everything. We have to figure out what’s going on. I think that’s a very good thing. We should also apply that to women. 

The clitoris and the penis are the exact same embryological tissue. When you’re an embryo, you get this hormone called testosterone that comes through. If you have a Y chromosome with the right genes, you have a penis, a scrotum, testes. If you don’t, you have labia, a clitoris. I outline all of this in the book. 

The clitoris and the penis, same tissues, get erections. Erections require nitric oxide, which we know those pathways can slow as we age. They also require good blood flow and circulation. 

Something that we know that is affecting far too many people in the United States that can impact our clitoral health/penile health is diabetes. If you have somebody with erectile dysfunction, you need to look at their cardiovascular health and diabetes. This is what I was taught in my nutrition science classes 20 years ago. The same is true of the clitoris. 

If someone starts complaining of inability or orgasm, simplest thing. I like to validate it. Yeah, it can sometimes be a struggle for a lot of different reasons. 

Getting older isn’t a death sentence for your sex life. In fact, many women who are post-menopausal report having much better sex at 50+ than their 20-something self. Part of it is you’re more comfortable with your body. Others is experience, and you understand your body more. But it’s also that the threat of an unintended pregnancy, which can mess with your nervous system, pull you out of the mood, is no longer there. They’re finding that they do orgasm better. They have a much better sex life. 

I want people to understand that. Not a death sentence. If you’re starting to struggle, get that investigated. Get it looked into. Something else might be going on. 

Now, the other piece that I want to say about sex as you age is lubrication is a must. If you are not having adequate lubrication, which as estrogen dips during certain times of your cycle, or post-menopausal, then you will need more lubrication. That is absolutely normal as well. 

I said that was the last thing I was going to say. I’m going to say one more thing about orgasms. The research tells us that only about 18% of women report being able to orgasm via vaginal penetration alone. That is based on their anatomy. Their ability to do that is based on their anatomy. Predetermined , nothing they can control. The distance. Where is the clitoris? Where is the vagina? This is important for people to understand because it may very well be you need more clitoral stimulation in order to reach an orgasm. That is completely normal. 

Dr. Eric: 

More foreplay, you’re saying? As an example. 

Dr. Jolene: 

I appreciate this. I talk about it in the book, about foreplay. Using the word “foreplay,” we all know what that means. I like to use common language, so we can arrive at the same place. 

We have to also recognize that foreplay is actually sex. It can be totally gratifying. You can achieve an orgasm. By the way, when you ask people, “Hey, remember the best sex of your life. Tell us what made it the best sex,” they don’t often report orgasm. I want people to understand that as well. Best sex of your life, people say things like intimacy, connection, vulnerability. They don’t say orgasm. 

We put so much emphasis on the orgasm. As a hormone doctor, I do think having an orgasm is great. If you can’t, we should investigate things. 

Understand that every sexual adventure, you’re not going to hit an orgasm. You may hit your orgasm in foreplay and decide not to have penetration if you’re in a heterosexual relationship. Or you might hit it in foreplay and have penetration and hit it again. It’s totally up to you. 

When we use the word “foreplay,” I never want people to feel the pressure. I want to acknowledge the pressure that foreplay is, to most people in their minds, the stuff that happens before, not the main event. But it can totally be the main event.

When it comes to clitoral stimulation, that can happen on its own, or it can happen in conjunction with a partner and having vaginal penetration at the same time. 

I list in my book a lot of ways to reach an orgasm. There are people who it’s like documented thinking off. People can just think about it and have an orgasm. 

There are people who go to the gym and work out and randomly have an orgasm. It’s called a coregasm. They are working their abs, and they did not intend for this to happen. 

There are a lot of ways to arrive there. However, the majority of people are going to only arrive there via the clitoris. Because the clitoris is not on the outside, like the penis, and it doesn’t have to pass urine and ejaculate- The penis has a lot of jobs to do. The clitoris has one: provide pleasure. 

The clitoral structure, what you see on the outside is the tip of the iceberg. The clitoral structure extends inside. Because of that, it can be more sensitive because it is more protected. It is not being stimulated all the time. Those neuronal pathways are the primary way that people orgasm. 

In the book, I also talk about people who have spinal cord injuries and how they find new ways to orgasm. This is how important pleasure is. I think If somebody is tuning out right now, or their doctor’s dismissing them, understand that the pleasure of being a human is so important that if you have a spinal cord injury, that pathway that went to the penis or the clitoris, those nerves will set up other places. Now, people are noticing that they can be stimulated on this other area of their body and achieve an orgasm. I want people to understand that that is because the brain is set up to be the big sex center, and it sends out those nerves, seeking out pleasure. 

Your body thinks it’s important. The World Health Organization thinks It’s important. The research says it’s important. This is not something we should take for granted. 

Dr. Eric: 

A lot more in the book for sure. Highly recommend everyone either read it or listen to the audiobook version like I did.

I have two quick questions, but they might not be two quick answers. If you don’t have time- 

Dr. Jolene: 

I’m gonna try. I talk a lot. I get excited. 

Dr. Eric: 

Just because nobody has spoken about the vaginal microbiome. The first question is if you can briefly talk about the vaginal microbiome and how to support it. And then briefly talk about your 28-day plan. I know people will have to read the book because there is no way to talk about the whole 28-day plan in a couple of minutes. Can you touch upon those two things before we wrap it up? 

Dr. Jolene: 

I just want to say I have ADHD. I write my books for brains with ADHD. You never have to read it front to back. You can jump in anywhere you want, and you can still get what you need out of it. Same with the plan. If you just want to jump in the plan, you can do that. While you’re going, go back and read it as you go.

You wanted me to talk about the 28-day plan. Before we get there, I want to get into the vaginal microbiome. Everybody needs to understand that it’s not just the vaginal microbiome; there is a cervical microbiome, an endometrial microbiome, a tubal microbiome, an ovarian microbiome. These microbes are everywhere. 

I talk all about it in the book. The biggest thing I think women need to understand is that your estrogen matters so greatly to the health of your entire microbiome. Your skin, your gut. As you enter menopause, we see that microbial diversity drops as estrogen drops. Your estrogen is so important. Your vaginal microbiome is no different.

Estrogen stimulates the cells that produce the glycogen that is the sugar that feeds the Lactobacilli in the vagina. Lactobacilli are why you have a pH that keeps yeast in check, BV out, and helps protect against other pathogens. Taking care of your estrogen as I outlined in the book is absolutely essential to taking care of your vaginal microbiome. 

I have an entire chapter about discharge and talking about BV, yeast infections, other types of infections as well. What you can do naturally to be working on that every day to optimize your vaginal microbiome. I think we are going to find in the future as it relates to cancers that there is a link to what’s happening in the microbiome there, not just by way of hormones, but also the inflammatory processes that can occur. That’s probably going to be like when I’m well into menopause. 

Don’t wait on the research. Just start taking care of your body now in the common sense ways that maybe your mama already taught you, and the new science is showing you that I talk about in the book.

28-day program. That is where we are going to get into how to optimize your hormones and how to understand your normal when it comes to sex throughout your cycle. I design the program so you can do the hormone thing if you want, or you can also bring in the sex stuff, too. You can understand your normal. 

The thing about libido and orgasms. We don’t go to our neighbors, “Let me compare my sleep to you,” and judge and shame myself for it. Are you talking to them about their periods and feeling shame and judgment? You are not. 

When it comes to libido and orgasms, we often compare ourselves to others and think something is wrong with us. Odds are, there is absolutely nothing wrong with you. We need to help you discover your normal. If we know that normal, you can get the pleasure that you want and also enjoy the hormone benefits that come along with it. 

Dr. Eric: 

Thanks for discussing all of this. Do you have two chapters dedicated to the 28-day plan? It was in great detail. It’s not spending 5-10 minutes on it. 

Dr. Jolene: 

There have been people who are like, “I got the audiobook, and I needed the real book to see the checklist, the charts, to go through the plan.” It’s a very interesting book because so many people have said they’re listening to the audio, and they have the physical book and are looking at it as well. That’s so interesting to me. That’s how I usually do things. 

With the 28-day plan, there is a chapter setting it up, so you understand the why, the how, what to be tracking. Then there is the actual plan, of let’s get in and do it. I separate it that way because I think it can become way too much information when it’s like, “You’re doing the plan. I’m explaining to you all the reasons why you’re doing the plan. Here’s the next step of the plan.” Some people don’t want the explanation. They just want to do it. 

Dr. Eric: 

Where can people get the book? Should they go to your website? Should they go to Amazon, like I did? Anything else you’d like to share? Social media? The resources? 

Dr. Jolene: 

If you go to DrBrighten.com/ITN-Resources, there is a four-week meal plan, a recipe guide for you to help you optimize your hormones. We have other bonuses and goodies there. It goes along with the book really well. You can grab it now. Pick up the book later. 

You can get the book anywhere books are sold. Of course, most people use Amazon. You can request it at your local bookstore or call your library about it. DrBrighten.com also has the book. We can ever rarely outcompete Amazon. I’ll just be honest there. 

Dr. Eric: 

You’re on social media. TikTok?  

Dr. Jolene: 

Instagram, TikTok, YouTube, Threads, @DrJoleneBrighten. 

Dr. Eric: 

Wonderful. Thank you so much, Dr. Jolene. It was awesome listening to your book. It was awesome chatting with you about your book. I’m sure the listeners learned a lot. I definitely did as well. 

Dr. Jolene: 

Awesome. Thank you so much. It was so great to see you again. 

Dr. Eric: 

Same here. Take care. 

Dr. Jolene: 

You, too. Bye!