Menopause with Dr. Felice Gersh: Rational Wellness Podcast 239

Dr. Felice Gersh discusses Menopause with Dr. Ben Weitz.

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Podcast Highlights

1:45  Menopause.  Is menopause a normal part of aging?  It is a normal part of aging, but a very negative one and it can lead to many of the diseases that we associate with aging. But it is also independent of age, since some women go through early menopause such as through surgical removal of their ovaries due to some disease.  “Nature is beautiful and wise, but also can be quite cruel.” The same nature that brings us beautiful sunny days also brings us tornadoes and hurricanes.

5:48  The first stage of menopause is Perimenopause, which is really the stage before menopause.  Menopause is defined as 12 consecutive months without a spontaneous period.  Menopause could also be called ovarian senescence, because it is marked by the ovaries no longer being able to produce estrogen.  Menopause is a natural, gradual process, but we should not ignore it nor embrace it. As humans we have a reproductive destiny and the prime directive of life is to reproduce and have healthy babies multiple times.  Every process in the female body is designed to support fertility.  The hormones, estrogen and progesterone, are the glue that glue all of the different functions in the body involving metabolic, cardiovascular, and immune function that go into pregnancy. When your ovaries can no longer function and ovulate and produce these hormones, all the systems in the body have this profound change.  It’s natural but it is a problem for women and once we understand that, we can create some viable solutions.

13:12  There is no definitive test that a woman is in perimenopause, though you could do a cycle mapping of female hormones, aka menstrual mapping. This test is available through Precision Analytical Lab as part of their DUTCH testing and also though ZRT Labs, where you have a woman measure her hormones daily using dried urine for 28 days or so.  This test is not done by conventional gynecologists, but it allows you to see the various phases of the menstrual cycle and you might see that they start to get a shorter luteal phase and the estrogen spike that proceeds ovulation will tend to be dampened down. Next you will start to see a dampened progesterone response as well.  The progesterone ends up being produced in a lower amount and for a shorter period of time.  This test can help with many conditions, such as fertility problems.

23:27  Phytoestrogens can help to manage some of the symptoms of perimenopause.  Eating organic, whole soy, which contains phytoestrogens, does not increase breast cancer risk.  This can help with hot flashes, night sweats, and sleep problems.  Estradiol has at least 3 different receptors–alpha, beta, and a membrane receptor.  Soy and flax bind to the beta receptors.  Beta receptors are in the cerebrum of the brain and in the cells lining the gut, so phytoestrogens help with brain and gut function, but bone is more alpha, so they don’t benefit the bone as much.  You can eat organic, whole unprocessed soy beans or minimally processed like tofu and include a couple of tablespoons of flax seed. Take Siberian rhubarb supplements, which is another phytoestrogen that is all beta.

37:10  One of the symptoms of perimenopause is mastalgia, for which Dr. Gersh recommends taking 100-200 mcg of iodine.  Also anti-inflammatory supplements like curcumin and fish oil, as well as eating an anti-inflammatory diet.

38:41  If the balance of the estrogen and progesterone tips and the progesterone declines first, chaste tree or chasteberry, aka, vitex can be helpful at a dosage of 200 mg per day.



Dr. Felice Gersh is a board certified OBGYN and she is also fellowship-trained in Integrative Medicine. Dr. Gersh is the Director of the Integrative Medical Group of Irvine and she specializes in hormonal management. Her website is IntegrativeMGI.com, and she is available to see patients at 949-753-7475.  Dr. Gersh lectures around the world, and she has just written her third book, Menopause: 50 things you need to know: What to expect during the three stages of menopause.  Her other two books are PCOS SOS: A Gynecologist’s Lifeline to Restoring Your Rhythms, Hormones, and Happiness and PCOS Fertility Fast Track and she has also published a very influential paper in the prestigious journal Heart, which is part of the British Medical Journal family of journals: Postmenopausal Hormone Therapy for Cardiovascular Health: the Evolving Data.

Dr. Ben Weitz is available for nutrition consultations specializing in Functional Gastrointestinal Disorders like IBS/SIBO and Reflux and also specializing in Cardiometabolic Risk Factors like elevated lipids, high blood sugar, and high blood pressure and also weight loss and also athletic performance, as well as sports chiropractic work by calling his Santa Monica office 310-395-3111. Dr. Weitz is also available for video or phone consultations.


Podcast Transcript

Dr. Weitz:            Hey! This is Dr. Ben Weitz, host of the Rational Wellness podcast. I talk to the leading health and nutrition experts, and researchers in the field, to bring you the latest in cutting edge health information. Subscribe to the Rational Wellness podcast for weekly updates. To learn more, check out my website, drweitz.com. Thanks for joining me and let’s jump into the podcast.  Hello, Rational Wellness podcasters.

Today our topic is the three stages of menopause, with Dr. Felice Gersh. Dr. Felice Gersh is a board certified OB/GYN. She’s also fellowship trained in integrative medicine.  Dr. Gersh is a director of the Integrative Medical Group of Irvine. She specializes in hormonal management. Her website is integrativemgi.com. She’s available to see patients at (949) 753-7475. Dr. Gersh lectures around the world. She’s just written her third book, Menopause: 50 Things You Need to Know, What to Expect During the Three Stages of Menopause.  Her other two books are PCOS SOS and PCOS Fertility Fast Track. She’s also published a very influential paper in the prestigious journal, Heart, which is part of the British medical journal family of journals. Post-menopausal Hormone Therapy for Cardiovascular Health, the Evolving Data.  Dr. Gersh, thank you so much for joining me again.

Dr. Gersh:           Well, it’s always a pleasure.

Dr. Weitz:            How should we think about menopause? What is menopause? Is it just a normal part of aging? Is it a disease? What is menopause?

Dr. Gersh:           It is definitely a normal part of aging, but a very negative one. It depends on how you want to look at all the diseases of aging. Menopause is not a disease, but it is a staging event that can lead to many of the diseases that we associate with aging.  In fact, that’s been a very big discussion, which has been very frustrating from me, when I was looking on from the sidelines. So many things that are attributed to just aging, like chronological age, have really been misguided because they’re missing that, I always say the critical ingredient of the hormonal ingredient, like what’s happening to women when ovarian function ceases and they don’t make any more estradiol and progesterone from their ovaries.  That is, of course, related to age, but it is also independent of age in that, for example, if a woman goes into a surgical menopause like, for example, her ovaries are removed for some disease entity, or she is unfortunate one of those women who has premature ovarian insufficiency, where her ovaries stop functioning at a very early age. Then all those conditions start to accelerate in their presence.

So, we definitely don’t want to think of everything that happens to women as just related to their chronological age. That’s why I really want to bring back the picture of menopause as natural, but negative. So I always say, “Nature is beautiful and wise, but also can be quite cruel.” The same nature that brings us beautiful sunny days also brings us tornadoes and hurricanes.  So, we just need to recognize the boundaries that we have in terms of what we can do about menopause and all of its subsequent negative effects, and what we can really take charge of. We can’t avoid menopause. I always said, Benjamin Franklin, who was very wise also, but a guy, he said something. To paraphrase, there are certain things in life that are never going to be done away with, and that was death and taxes.  I said, “Wait a minute. Just one minute here. What about menopause?” We can’t escape menopause. At least at this time, although I hear there are some people working on cloning ovaries, but that’s not happening quite yet for the market.

Dr. Weitz:            Right. It’s interesting, the discussion about whether or not menopause is a disease. There’s also a discussion in the longevity section of medicine, whether aging is a disease. A number of doctors are lobbying for aging to be a disease, so it’s easier to justify treatments for it.

Dr. Gersh:           I would probably draw the line of calling aging and menopause diseases, but I would say that we need to look at what is happening. I’m always into mechanisms. I know you are, too.

Dr. Weitz:            Theoretically, of course, we don’t want to see aging as a disease. But the way our healthcare system is, where we don’t do anything for prevention, you have to call something a disease before you can even justify treatment.

Dr. Gersh:           If we need a CPT or ICD9 code, I guess for menopause and aging so that we can actually get coverage for caring for people, then I’m for that. I have to be pragmatic, as well, so I’ll buy in.

Dr. Weitz:            Let’s go into the stages of menopause. The first stage of menopause is perimenopause, which is really the stage before menopause, but you’re approaching menopause, right?

Dr. Gersh:           I have to work with the existing vocabulary. If it were my choice, I would abolish the word menopause because it has really misguided so many people into viewing this process of ovarian aging, or ovarian senescence, as really about the end of periods. By arbitrary definition, menopause is defined as 12 consecutive months without a spontaneous period. That is completely arbitrary. There’s nothing in nature that points to that as anything other than that it’s part of the process.  Part of the reason I wanted to do three stages, I can’t get rid of the word menopause. That’s stuck. In medicine, we’ve tried to change words. The old word is just added to the new word, and everyone falls back to the old word, because that’s what we feel comfortable with. So I’m not going to abolish the word menopause, so I have to work within that context.  To try to show menopause as what it is, it’s ovarian senescence, and it’s an evolving process. That’s why I, somewhat arbitrarily, created the three stages of menopause, so that people would see that there’s the prelude to this arbitrary definition, and then there’s the first decade. I put the first part of menopause, after the pre-menopause is 10 years because-

Dr. Weitz:            Maybe you should come out with two versions of the book, and call one Ovarian Senescence, and call one Menopause, and see which gets the most attention.

Dr. Gersh:           Okay. You know what? That’s an idea. I’m going to hire you, marketer.  We have to stop thinking of menopause as, you cross a finish line and you’re there. The event has happened and I made it, and I’m still alive!  But to view it as what it is. Of course, aging, people always talk about the minute you’re born, you’re aging. But the bottom line is that there’s certain things that, we’ll say accelerate the negatives of aging, or the process of menopause. We need to understand this if we’re going to actually put into place some pragmatic ways of approaching it. Just because it’s natural, doesn’t mean we ignore it or embrace it. In fact, everything in medicine is about recognizing things that may be natural, but are negatives, and then doing things that are completely unnatural to try to get people back to that state of homeostasis.  Everything that is medicine, even going back to the days of a tribe, where you had the person who was in charge of healthcare in a tribe, they were incorporating natural things. I’ll call it green medicine. They were looking for plants that could reverse a fever, or a pain, or something.  So, everything is about harnessing whatever tools we have to reverse something that’s happening, that we don’t view as a positive, like all the stages of menopause, and all the symptoms I put in there, that people will often experience, and what we can do about it, and recognizing, really. The takeaway that’s so essential from the get-go is that menopause is not a one time event, and that it’s an ongoing process, and that it’s a gradual process involving the declining function of the ovaries, which actually does parallel the declining state of fertility. That’s not an accident.

Dr. Weitz:            Right.

Dr. Gersh:           Once you also, I keep telling people this, and I want it to really come home to roost. Every process in the female body is designed to support fertility. We don’t like to think of, our bodies are designed just to procreate. We just need to recognize that we, as humans, are so unique in that we actually try to determine our reproductive destiny. Whereas, no other creature on this planet says, “This is not a good year to have a baby.” That is just not happening. Or, “I think I’ll go on birth control for the next 20 years.” That doesn’t happen. We do that to our pets when we castrate them, but nothing happens naturally in nature that involves trying to control reproductive function.  Since the prime directive of life is what it is, it’s the most amazing thing of life. Remember, I’ve delivered thousands of babies and it never ceased to astound me that this is actually happening; a baby was coming out of another person. It’s like, “Wow. This is amazing.” That is really the prime directive of life, so every system in the female body is really designed to help to have a successful reproductive status, and have healthy babies, and do it multiple times.

Pregnancy is such a stress test of women. It’s such a challenge, too, with altering the cardiovascular system, and changing the immune system. All these systems in the body are so amazing. I say that the hormones; estrogen, progesterone; they are really the glue that glues all of these different functions in the body involving metabolic functions, cardiovascular, immune functions, everything in the body to the reproductive functions. In fact, all of the different enzymes, pathways, are actually reproduced in the reproductive tissues that are out there in the peripheral tissues.  So, it’s a sink or swim together body. That’s the takeaway. When you lose reproductive functions, when you go through this dynamic change and your ovaries are no longer going to be ovulating, putting out the eggs, you really can’t have babies anymore; all the systems in the body have this profound change that occurs in them because of the loss of this vital force in the female body, which are these beautiful rhythmic hormones.  We need to recognize that, and be honest about it, and then decide, “Okay, what are we going to do about it?” That’s really my mission is really to first educate, because you’ll never solve a problem if you don’t first define the problem. The problem, I call it natural but I call it a problem for women, that menopause is a problem. If you cannot define that problem, I can consider a premature death as a problem, too.  So, if you define a problem, then you can come up with viable solutions to that problem. But if no one even understands what is menopause, what is happening, what are the implications, then clearly, we’ll never have any viable solutions. That’s not going to help women everywhere.

Dr. Weitz:            So how do we know a woman is in perimenopause?

Dr. Gersh:           There is actually no test. It’s a clinical. We do have clinical. I can’t believe this, but I am actually a very old fashioned doctor. I observe. I take a history. I do an exam.  We know, 100%, since 100% of women are going to go through menopause, that at a certain age, it’s going to be a process of ovarian decline and fertility decline. Women will manifest the symptoms quite differently. There’s really a huge range. But every woman, once she hits the age of 40, is definitely going to be having serious fertility changes and serious changes in her hormonal production.  Now, we can do certain tests. I say there aren’t any, but you could do a menstrual mapping. It’s very interesting because I’ve done a lot of those tests. That’s not really mainstream at all. But if you take a woman, and what’s very classic for women as they are in the last decade before the end of cycles, we’ll call it, they will often have changes in their menstrual cycles, but they’re still having them.

So often, the cycle will become shorter. So then you think, “Okay, why is the cycle getting shorter? What’s happening?” If you do a menstrual mapping, then what you will often find is a shorter luteal phase. What happens is, the estrogen spike that proceeds ovulation is dampened down. Then you’ll see a dampened progesterone response.  So, the progesterone should have this nice, rounded little mountain, like a hill. Then instead of being like that, it’ll often be like this. It’ll have a little spike and then it comes down. You’ll actually see that the progesterone is produced in a lower amount, and also in a shorter period of time.  Of course, we know, everyone should know that progesterone is essential for the establishment of a pregnancy. That’s why in IVF clinics, they’re always giving progesterone to everyone for the first three months or so, because progesterone is essential for proper implantation. It works with the endocannabinoid system, so it’s all complex. If you don’t make an adequate amount of progesterone for a long enough period of time, and then allow the placenta to take over and so forth, then you’re going to have a miscarriage. Miscarriages are much higher in their incidents in women who are older, in their 40s and such.  The bottom line is that there’s not a test. You could do things like FSH-

Dr. Weitz:            By the way, on the cycle mapping, just for those listening who don’t know what that is. Can you just explain what cycle mapping is?

Dr. Gersh:           Sure. It’s a wonderful test that can help with many diagnosis, like is a woman having an inadequate spike of estrogen, or LH spike and they’re having fertility problems, they’re having PMS, and so on. What it looks at is through urine, by measuring urine multiple times during a cycle, you actually get a mapping.  So, if you’ve seen a menstrual cycle that’s been graphed out over 28 days, you see the estradiol, and it goes up, and then you have the big spike, and then it comes down, it dips and then it comes up. Then, if you’re not pregnant, it goes down. Then you see the LH, and it will have a big spike right after the estradiol spike, and then you see the progesterone coming up right after ovulation. Then, if you’re not pregnant, it goes down.  All of this gets mapped out on your graph. Then you get to compare it to an ideal one. Then you can see, “Oh, my gosh.” Now, it’s only telling you that one cycle, but hopefully, it’s a classic, typical cycle for that particular woman at that stage of life. What you can see is her estrogen, and the estradiol level is not right. Or you see the LH may be hovering too high because she’s perimenopausal and she has too much LH. Then we also see the progesterone, which often will be inadequate in its quantity and duration.  So, you can really help, a woman has PMS. Then you say, “Oh, yeah. Her progesterone level, or her estradiol level is totally inadequate.” Then we can, instead of just randomly giving people hormones and saying, “Here, I’ll just give you this hormone and see.” No, it’s a much more scientific approach to actually measuring, and then treating, and then seeing, monitoring for the effect.

Dr. Gersh:           So, I love to be evidence based. I hate to just be throwing hormones at people, which is done too often.

Dr. Weitz:            This cycle mapping is available through Precision Analytical. It’s part of their suite of DUTCH Labs, and also through ZRT. This is the kind of test that you might get from a functional medicine practitioner, gynecologist like yourself, which is not, you’re not going to get this from a conventional medical gynecologist, or hormone specialist.

Dr. Gersh:           No. It’s really, actually when you realize what you’re getting, and how valuable this information is, and how completely off the grid it is for the standard OB/GYN, it’s really sad.  So for those of you out there, this is very easy to interpret, and the labs will also help you to interpret them. They give a lot of examples. It’s really fascinating because I have found that so many women who have even regular cycles, when you look at their hormone production, it’s really not optimal at all. It’s very interesting when you see perimenopause and you see where, sometimes, they’ll have an overshoot of estradiol, and you have a really high sustained LH.  So these are really interesting. These are not standard, run of the mill kinds of approaches. Because in the standard, conventional world, they do not do anything for perimenopause. They don’t even really recognize perimenopause. They just mostly, I hate to say this, but they put women, very frequently, on SSRIs. That’s the go-to. Really, it is, because women are having a lot of symptoms and they always say, “Ugh, another crazy woman.” Then, “Why don’t you just go on some Prozac or Lexapro?”  This is standard of care, which is really frightening because that is not addressing, we talk about root cause. That is not the root cause.

Dr. Weitz:            Unfortunately, it’s part of a small bucket of drugs that are used for conditions where they don’t know how else to treat. So, SSRIs are used for perimenopause. They’re used for irritable bowel syndrome. They’re used for, sometimes chronic pain patients. When you don’t know what else to do, try an SSRI, or try a PPI, or try an NSAID.

Dr. Gersh:           Right. When you know that these hormones are very involved in every organ system, including the brain. They’re involved with both cognition and with mood. Now it’s been published that the majority of women, as they are going through the perimenopause, in their 40s, they will have mood swings, sleeping disorder, and also some brain fog.  So, the go-to is traditionally to go on an SSRI. Upwards of 25% of American women in their 40s are now being prescribed an SSRI. That gets back to my, let’s define the problem so we can get a better solution than that. Because SSRIs, I’m not-

Dr. Weitz:            By the way, these drugs are not benign. They’re very difficult to get off of.

Dr. Gersh:           Very.

Dr. Weitz:            We’re manipulating brain chemistry in a very narrow way. We really don’t have much of a clue as to what we’re doing.

Dr. Gersh:           It’s really interesting because during the perimenopause is when bone loss is actually accelerated. It’s not really well recognized because you don’t have the fractures, but you have that accelerated bone loss as the hormones are going down.  SSRIs increase the risk of osteoporosis, so I call these the crazy maker drugs. There’s a ton of them. They actually promote the very problems in this specific demographic that we’re trying to avoid. Then we go on a drug that actually promotes the very condition that we ultimately are trying not to have.


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Dr. Weitz:            Let’s talk about some of the lifestyle factors and/or nutritional nutraceuticals that can help manage a woman with perimenopause.

Dr. Gersh:           I love phytoestrogen. Now, poor phytoestrogens have also gotten a bad rap, because people don’t understand them, and they think that somehow they promote all kinds of disease, when they actually are quite the opposite.

Dr. Weitz:            Like breast cancer.

Dr. Gersh:           Yeah. No, they’re actually not. If you eat organic whole soy, you’re not promoting breast cancer. It’s actually, these are actually agonist for the beta.  Now, we recognize plants are not estrogen. It’s a miracle of nature that certain plants can actually bind to our own receptors. We know cannabis binds to our endocannabinoid receptors. So, we have this miracle of nature where plants combine to our own receptors for our own benefit. There are a whole group of different types of plants. We can do plant extracts, as well, and utilize them for helping to maintain gut health.  There was actually a very interesting study that came out, maybe three to four months ago that showed that if you had an organic, soy based diet; a cup of organic soy like tofu or edamame; every day, that by the end of 12 weeks, hot flashes, night sweats, and sleep problems, which are so prevalent in this transitional time. Of course, it can go on for almost 20 more years. It can go on for a very long time, that something like close to 90% resolution of these symptoms, just by including these phytoestrogen foods.  Which is amazing, really, because they bind to the beta receptors. Estradiol has at least three receptors and variants now. There’s offshoot receptors, but the primary receptors are alpha, beta, and a membrane receptor. They have prevalence throughout the body, but in different proportions. They have different effects and they actually up and down regulate each other. They’re very interactive.

It turns out that certain foods like soy and flax seed predominantly bind to beta receptors. Beta receptors are in the cerebrum of the brain. So, it helps with that type of function, and as well, the gut lining cells are mostly beta. So, it helps with gut.  Now, unfortunately, the bone is more alpha, so it hasn’t been shown to improve bone health. It’s not a panacea. It’s not a panacea, and it’s not like having estradiol, but these are ways of harnessing nature’s gifts to us, to help us to feel better, sleep better, and all of those things are going to improve quality of life dramatically.  So, I recommend including organic, of course, if you have a food sensitivity, there are people that can’t eat some of the healthiest foods on the planet because of leaky gut and how their bodies have modified their ability to deal with them. But assuming you don’t have that problem, and you can do elimination diets and check it out, but assuming you don’t have a problem, and you can eat organic, whole, unprocessed soy, or minimally processed, like tofu, and include that on a regular basis, along with a couple of tablespoons of flax seed, that alone can have dramatic effects.  In terms of supplements, you can harness the Siberian rhubarb. The root of that plant is also a phytoestrogen that is all beta. That’s been well tested.

Dr. Weitz:            Let me just clarify for some that don’t understand. Phytoestrogen stands for plant estrogen. So, these foods like flax and soy contain these plant compounds that are very similar to the estrogen that’s in your body, and attach to those estrogen receptor sites.  Then the question is, do they have negative effects? Could they increase the risk of breast cancer, or some of the negative effects that can happen? Or are they more likely to have positive effects?  A lot of the data seems to show that most of their effects are very positive, that in some ways, they block out some of the toxic estrogens that are found from toxins in the environment, like pesticides and all these other chemicals. So, you’d much rather have phytoestrogens attached to your estrogen receptor sites than estrogenic substances coming from petrochemicals, or pesticides, or et cetera.

Dr. Gersh:           Yeah, plastics, right. Absolutely.  These, if you look at the chemical structure, a little bit of the molecule is similar enough that it can actually bind and have a positive effect. Then there are other foods that can also have that people don’t even realize, like pomegranates, which have been called a superfood, and people don’t realize that from pomegranates, you get urolithins. Urolithins are the breakdown from the different polyphenols; the aegisic acid and so on. These actually can also be phytoestrogen effects.  So, many of the foods that are called superfoods, when you actually find out about it, they’re actually phytoestrogens. So many so called superfoods actually do bind to estrogen receptors because, of course, men, I always say, should love estrogen, too. They have tons of estrogen in their body. They just make it locally, on site, in the different organs, from their testosterone. Because all estradiol is derived from testosterone. Men just do it on site. Women make it in their ovaries and then disperse it. Of course, we have different quantities, different ratios.  But in the end, these foods can also be beneficial. Breast cancer, by the way, is virtually always, when it says estrogen receptor positive, it’s working on the alpha receptor. Like soy, flax seed, they’re beta receptor. They’re more like estriol. They actually, we know that when you have a lot of beta receptor stimulation, it actually down regulates alpha. It’s an interesting thing.

So, it’s a little bit like taking raloxifine or tamoxifen, but better. These are drugs that have other interesting but not desirable side effects. It’s nature’s own way of giving these drugs that are actually marketed, like raloxifine, which is also called a SERM. The name SERM is not supposed to be used anymore, but like I said, nobody ever gets rid of the old words.  So, that stands for selective estrogen receptor modulator. But now you’re supposed to say estrogen agonist/antagonist. It means that depending on the location and the receptor, it either acts as a pro or a con. It stimulates or it blocks. So, that’s the new word, but we always say SERM anyway.  So, this is a drug, a pharmaceutical, raloxifene, and the brand name is Evista, that has an FDA approval for bone health, and to help reduce fractures of the vertebra, not of the hip. They haven’t shown hip. But in terms of breast cancer, it’s considered a prophylactic preventative, to help reduce the risk of breast cancer.  Well, duh. You could eat food and then you get all the other benefits of food, but those are natural ways of creating a similar effect to this pharmaceutical. So, I say go for the food.

Dr. Weitz:            What about topping off the benefits of the food by taking, say, genistein or diadzen supplements as well?

Dr. Gersh:           So, in terms of the isoflavone concentrates, I wish that the data was more robust in terms of its benefits. It hasn’t been as good as I would like. I don’t know of any real harm, but for those particular isolates of the isoflavones, you do better by eating the whole food.  So, I don’t actually push for those isolates. In terms of others, there’s been some extracts from what are called lignans, which are also phytoestrogen. Also, as I mentioned, the root of the Siberian rhubarb plant. That seems so arbitrary, but they figured that one out.  You’ve probably heard of black cohosh. Now, black cohosh has also not quite panned out as well as we had hoped. So, they’re just not really nature’s gift to the world as much as we’d hoped. So, I don’t really use a whole lot of black cohosh. I do use some of the others; the lignans, and I do use the Siberian rhubarb root. Then I use food. Of course, as an MD, I do use hormones.  That’s another thing that is not really recognized, that you can give a little bit of bioidentical estrogen, even to women who are cycling. That’s where, if you do the menstrual map, and you see that their estradiol levels are really sub-par, but it’s a crazy time, also mentioning the perimenopause, because there’s a lot of overshoot. That’s the one time when you can have actual estradiol dominance.  People always throw this term around, of estrogen dominance. I’m trying to get rid of it because people think of it as estradiol is evil, and that’s not what estrogen dominance is about. It’s about poor detoxification, endocrine disruptors. It’s not about, the ovaries are making too much estradiol. That’s not what it is about.  Except in one case, and that is when a woman is perimenopause, and she ends up having too little estrogen. The brain, which has a censor says, “Oh, there’s not enough estrogen being produced from the ovaries, so I will tell the pituitary gland to make more of its gonadotropins, LH and FSH, to then trigger the ovary to make more estrogen.”  Well, unfortunately, the ovary is now less responsive because it’s running out of eggs and it doesn’t really make the hormones as well. So, the gonadotropins, LH and FSH, are produced in higher quantities. When you still have some reserve, the ovaries are not completely done for yet, then you have this giant surge of LH and FSH. You can get a giant surge of estradiol, and you can also get multiple eggs coming out.  That’s why women in their 40s have the highest incidents of fraternal twins of any time in a woman’s life because they’re getting hyper stimmed. It’s like what they do when they’re trying to help women get pregnant, like in fertility patients. They give these medications to try to get them to ovulate. Then, sometimes, oops, now we’ve got too many.

Now, in the ancient days, they weren’t so careful and then people had octomoms, they got so many eggs out.  Now sometimes they’ll get twins. They’re very careful. They’ll just abort the cycle if there’s too high of a level. But in nature, nature can do that, and then you get twins. It’s like, “Oh, my gosh. I thought I was not even fertile anymore and now I’m pregnant with twins.”  That happens when someone’s 44. That actually can happen.  But women, because they’re going through this, I call it a roller coaster, where their estrogen is too low. Then they have this giant overshoot of gonadotropins, and suddenly their estrogen level is, I’ve measured sometimes, it’ll come out … A typical level for a woman would be around 100 or so, for picograms of estradiol. Then I’ll get a level of 800. It’s like, “Oh, my God!”  So, this can trigger horrendous migraines, and sleep problems, and mood swings, and breast tenderness. Suddenly they get really, really heavy periods.  You can just imagine how much uterine lining is made by all that estrogen.  Sometimes, if you give a little background, a little bit of estradiol, it’ll keep the brain from creating that giant overshoot of gonadotropins.  So it’s like, if you give a baseline of estradiol, the brain won’t create this roller coaster effect.  Sometimes that can really be a saving grace as women are going through this really challenging time because the conventional world puts them all on birth control pills.  I can tell you that.  But that has its own set of issues, as well.  So, we try to do it and let women still have real hormones, their own natural hormones. But we’re trying to tame the monster here a little bit, during that time when they can have this crazy overshoot.

Dr. Weitz:            Let’s go through some of the symptoms of perimenopause. I want to say, looking at the time, I don’t see how we’re going to get through all three stages because we’re still on stage one, but that’s okay. Let’s do a good job with what we’re doing.

Dr. Gersh:           Oh, they’ll have to read the book!

Dr. Weitz:            Exactly. Exactly.  So, you mentioned breast pain/mastalgia, and that’s often common in perimenopause. Why is that and what can we do about that?

Dr. Gersh:           Well, that’s because of this overshoot, often, of the estrogen. So, the best thing that you can do for that is to have a little bit of patience, and often to take a little bit of, I recommend a little bit of iodine can be helpful. Sometimes that’s a sign. We have massive iodine deficiency, so a little bit of iodine can be helpful. But a lot of patients can be really going-

Dr. Weitz:            When you say a little bit of iodine, you mean 100, 200 micrograms?

Dr. Gersh:           Yes. Yes. Always less than one milligram. So yeah, around 200 micrograms. I am not into massive dosing whatsoever.  Then you can do things that reduce inflammation because remember, pain is always inflammation. You can take some of the anti-inflammatory, herbals is very helpful.

Dr. Weitz:            I take curcumin or fish oil.

Dr. Gersh:           Yes. I love all of those things. Then having the anti inflammatory lifestyle. Really, it’s so important for women to know that this is just a stage, and that it’s not associated with breast cancer. Sometimes reassurance is the best medicine, rather than going on pharmaceuticals for something like that.

Dr. Weitz:            What about if the balance of the estrogen and progesterone is tipping, that the progesterone is starting to go lower, and maybe getting these spikes of estrogen? What about using something like chaste berry to help the body produce more progesterone?

Dr. Gersh:           Yes, absolutely. Chaste tree, also for the Latin name, vitex, is often referred to as the women’s herb. It has actually reasonable data that has been accumulated, showing that it can help with PMS and breast tenderness. Those are really key problems that often go together, actually, because it’s a hormonal imbalance. So yes, chaste tree, vitex is a very, very useful herbal for treating breast tenderness.

Dr. Weitz:            What dosage for that do you like?

Dr. Gersh:           Usually about 200 is a very good dose. For taking it, I always recommend just take the whole dose in the morning, just as a morning dose.


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Dr. Weitz:            So, fibromyalgia. That’s a not quite fully understood condition, seems to be fairly prevalent. Patients get pain throughout their body, up and down their spinal cord. How is this related to perimenopause and how frequently is this seen?

Dr. Gersh:           It’s seen all too often and it’s primarily in females. That’s why it’s been swept under the rug quite a bit, and treated a lot with Prozac in the past, and still treated with Cymbalta, which is duloxetine, which is in the SSRI/SNRI family. It’s interesting because some of the same centers in the brain that deal with pain response also deal with mood response.  So, in terms of pharmaceuticals, some of the drugs that are used are gabapentin. But we can do a lot without turning to the pharmaceuticals. So, understanding that there is a strong relationship to hormones. All of the hormones have a lot to do with balancing our endocannabinoid system and our opioids or natural endorphins. It turns out that these hormones are very involved, all of them; progesterone, testosterone, estradiol; in terms of the relationship of these different other systems of the body.  We have all these different interesting systems involving signaling agents. We have the peptides, and we have the fatty acids, which are involved with the endogenous opioid system, and the endorphins. We need to have proper hormones for transporting these molecules into the brain, for having them function properly in the brain, for balancing all of this.  We now know that, although fibromyalgia doesn’t typically have systemic inflammatory markers present, that they can actually be in the spinal cord. It still comes back to pain is inflammation and it’s going on in the central nervous system.

So, we still need a lot of research on fibromyalgia, but a lot of mind/body medicine can be helpful. Trying some balancing hormones, I find is actually very beneficial. Sometimes gentle body work, but not heavy, not pushing too hard. But gentle body work, lymphatic massage, mind/body medicine, and sometimes, short-term, some of the pharmaceuticals, and once again, all of the anti-inflammatory herbals. It’s amazing how we now know that without adequate vitamin D, you’re going to have more pain. Omega 3, you’re going to have more pain. We know that people have, often, very bad diets that are lacking in the antioxidants, the polyphenols.  So, just getting on a diet that is plant based, filled with different colorful vegetables, fruits, and proper fiber, because I’m sure there’s, we’d need more research, but there’s always a relationship to the gut microbiome. So, anything we can do to improve the gut microbiome, have proper short chain fatty acids like butyrate, that’s going to affect the brain.  So, we definitely have to work with lifestyle, mind/body medicine, and gentle exercise like stretching and yoga can be incredibly beneficial.

Dr. Weitz:            Some of the data seems to indicate that fibromyalgia is related to mitochondrial function.

Dr. Gersh:           Estrogen is also the under recognized, because a lot of people talk about aging is related to mitochondrial decline. Estradiol is essential for every single function that is involved with the production of energy in mitochondria.  Also, not just a production of energy. Most people in the functional medicine world know that when you produce energy through [inaudible 00:45:15], you’re also creating oxidative stress, like with superoxide. It turns out that estradiol actually is key to regulation of this very essential enzyme, superoxide dismutase, which helps to detoxify this toxic oxidative stress molecule, the superoxide. So, without that, you then have destruction of the cell and of the mitochondria.  The bottom line is that estradiol comes back to yes, you need estradiol to manage your healthy, functional mitochondria. Absolutely mitochondria, or the energy producing factories. If you don’t make energy, you’re not alive. In fact, everyone knows, if you flat line, that means you’re not alive. You need energy. That’s the spark of life. Estradiol is like the spark of life, by helping mitochondria to make that critical energy.

Dr. Weitz:            Certain minerals, zinc, coper, and manganese are precursors for SOD, so those should probably be included there.

Dr. Gersh:           Right. That’s why so many people have essential deficiencies of these key, I always say you can’t work the machinery of yourselves if you don’t have the right nutrients. That’s why everyone who comes in, and weight gain, we’ll have to come back after, but in terms of the gaining of the weight and the fat redistribution, which is so distressing to women. We know that this can also be very much related to declining estradiol levels, but we can do so much about that. Not just taking hormones, which is part of the equation, but doing proper stress management. There’s nothing that contributes to belly fat more than high phonic levels of cortisol. We’ve got to work on our stress and our sleep. Exercise revs up mitochondrial function. We know that you can have mitogenesis just by having great exercise.

So we have to work with what we have. I say, that’s why I dislike to the bottom of my heart, centers that are just hormone distributing centers. I’m not going to compare it to opioid distributing centers, which exist, where people would come in and get their dose of an opioid every month.  But just giving out hormones is offering false hope because hormones are just a piece of what makes women healthy or men healthy. You can’t just give hormones and expect that’s it. No. You have to do all these other things. You need to have stress reduction, sleep, and so on. Because this belly fat thing is so harmful to women’s self-esteem. Of course, it’s a metabolic poison and creates that chronic state of inflammation, creating that well known term, “inflammaging.”

Dr. Weitz:            Yeah, this whole concept of fat loss, and why different people gain fat in different areas; whether it be more in the abdominal region, more in the hips, more in the back, et cetera; it really hasn’t been studied that much. We know it’s related to these different hormonal balances.  I remember the late Charles Poliquin, who was not a medical doctor, but a very interesting practitioner of exercise and recommendations about nutrition. He would have these categories for, this is an insulin dominant person, this is cortisol, based on where their fat was distributed. That’s something I think really should be given some more attention and study.

Dr. Gersh:           Oh, absolutely. We’re always challenged, as you brought up earlier, with these ubiquitous endocrine disruptors that are really metabolic poisons. Then, when you don’t have your proper production of hormones, then what becomes the dominant hormone, if you can call it [inaudible 00:49:29] information.  So, once you recognize hormones are really the language of the body. There is multiple different languages, but these are the main language. They tell the cell what to do. They’re giving instructions. If you get endocrine disruptors, then you’re going to get the wrong instructions, and the cell will do the wrong thing; make the wrong protein, for example. If you have no information, then the cell goes into a default state, which is pro-inflammatory. The whole body goes into this default state of pro-inflammation.  It’s really interesting when you see estradiol as operating the switch. I think of it as a switch that turns the body from pro- or anti-inflammatory, back and forth. That’s why estradiol is an immune system modulator. That’s why it can be so confusing to people. It’s like, estrogen causes inflammation. Estrogen is anti-inflammation. It’s both because it’s modulating the immune cells.

So, that’s why when you get a pathogen that tries to get into your body, it’s estrogen in the form of estradiol that triggers the [inaudible 00:50:40] to become activated and the mass cells to become activated. So it basically revs up your innate immune system. Then later, it also triggers the production of antibodies, but then it dampens down. It flips the switch so that you go back into the homeostatic state where you have an anti-inflammatory state.  So, estradiol, when you have proper production, it modulates this entire immune system response. Which of course, is also activated if you have damaged tissue. Then, when you don’t have it present, you end up getting into this default system where you end up in a chronic state of pro-inflammation. That leads down the path to all the other things that happen in the other stages of menopause, like hypertension, and heart disease, and then really the fractures, and the disintegration of your joints, and then having the osteoarthritis.  So, all of these things stem from, really, loss of this modulation of the immune system that regulates how you’re either pro- or anti-inflammatory.

Dr. Weitz:            It’s hard to get my head around exactly how it affects immunity because we know that women tend to have stronger immunity prior to menopause. Yet, after menopause, they seem to have increased autoimmunity. So, if the estradiol is so crucial for immunity, and then the estradiol drops after menopause, shouldn’t they have less autoimmunity rather than more?

Dr. Gersh:           It’s interesting because it depends on, there’s different types of cytokines and the different immune cells, but every immune cell in the body has estrogen receptors. The dominant receptor on the cells that make antibodies is the beta receptor. The dominant receptor on the innate immune cells that make the inflammatory cytokines are predominantly alpha.  So, you have this balance between this whole immune system that is then lost. When you don’t have enough estrogen, and this has been shown, the innate immune cells will release their inflammatory cytokines at a lower threshold of stimulus. So, you get altered gut microbiome. This has been now shown. When you lose your estrogen, the microbes in the gut transform into a different set of population. Then you lose your protective mucus coating and you have the impaired gut barrier, or leaky gut.

As these endotoxins, the lipopolysaccharides cross between the lining cells into the gut associated lymphoid tissue where 70%, 80% of the immune system resides around the gut. These innate immune cells are triggered through the toll like receptors that activate them, that the little [inaudible 00:53:42] cells, they put their little fingers into the gut, and they communicate, they all line up.  Then you have this explosion of production of inflammatory cytokines. But as well, you have the connection between these innate immune cells and the lymphocytes that are in the peyer’s patches. These are segregations of lymphocytes that make antibodies that are embedded in the gut associated lymphoid tissue, and they make antibodies, and they communicate through these different types of toll-like receptors. So, they are then triggered into making antibodies.

When you lose estrogen, you actually lose a lot of your control over all these incredibly, critically important and very complex functioning immune cells, so you end up with that situation. We know, for example, when you’re exposed to a lot of endocrine disruptors, and I was trained in environmental medicine under Dr. Walter Crinnion, who I just miss every day. He’s an amazing pioneer in environmental medicine.  Basically, his foundational tenant of life is, most problems are due to pollution, and what is altering the ways our bodies are functioning, because we’re getting all these ridiculous toxic chemicals into our bodies, and that most of the auto-immunity that people are now facing in younger years is because these are endocrine disruptors that are interfering with the normal signaling.  So then, that promotes early onset, like Hashimoto’s, which is epidemic, and also lupus, and multiple sclerosis and such in younger people. Then in older women, rheumatoid arthritis becomes really prevalent. Of course, you can have endocrine disruptors that are contributing, but it’s really the loss of the control of the immune system’s homeostatic mechanisms, by loss of the estrogen.

Then the immune system goes into this crazy state of producing lots of inflammatory cytokines, and then communicating with the lymphocytes to make these antibodies. That’s why we now know that these autoimmune diseases, like rheumatoid arthritis are not just associated with joint damage, and motor disabilities, and pain, but also with cardiovascular risk. That because you have a systemic state of inflammation.  So, it’s affecting the immune system on multiple levels. That’s why you really want to be proactive, because we want to be helping women with both diet, lifestyle, and hormones, so that they don’t get rheumatoid arthritis, which is really incredibly prevalent, and really harmful in a myriad of ways. That tends to show up down in the later phases. But the precursors are happening in the perimenopausal years, when the immune system is starting to get this hit of lack of hormones.  Then of course, the immune system is everywhere, including in the brain. So women who have loss of the hormones have a much higher rate, and this sounds so politically incorrect, but I have to tell the truth. Women have two times the incidents of Alzheimer’s as men. It’s not an accident. It’s because their immune cells in the brain, which are these specialized macrophages called microglea, when they don’t have the proper estradiol to regulate their function, they too, go into this default state, like weapons of mass destruction. They produce enzymes. All these immune cells, these macrophages, produce enzymes that are designed to dissolve pathogens and damaged tissue and then gobble it up.  That’s our cleanup crew, our damage control mechanism. But what happens when they can produce and release these dissolving enzymes for no good reason. Then they dissolve our brain. That’s when the brain tries to have a healing mechanism. Then it produces the beta-amyloid. That’s why getting rid of the beta-amyloid doesn’t prevent Alzheimer’s, as I wished, because it’s a response to these out of control microglea, these immune cells that are producing all of this inflammatory response.  But this is what’s happening elsewhere. That’s what’s happening in our arteries. It’s a similar thing that’s happening in different organ systems. That’s why I love talking to you, to get the word out, because these are not in-solvable problems. Because it sounds so terrible, the future is so grim. But we can actually do so much to work out all of these issues.

Dr. Weitz:            But it’s going to take a lifestyle program. It’s going to take more of an Integrative, Functional Medicine approach, and there’s not going to be one drug that’s going to solve it.

Dr. Gersh:           No, including hormones.

Dr. Weitz:            We’re going to have to wrap here. I was worried about getting through the three stages of menopause, but we didn’t get halfway through the first stage.  Buy Dr. Gersh’s book.

Dr. Gersh:           Well, now really, to give a slight plug, it’s not a book that you have to read from beginning to end. It’s like a little compendium, like a little mini encyclopedia. You can just pick out, one of my favorites because I see women all day long, and they look in the mirror because that’s what we do. We say, “What’s happening to my lips? Why are they getting so thin?”  This way you can say, “I don’t know why my lips are getting thin.” You can look it up in the book. Or, “Why am I getting breast tenderness,” like you said or, “What’s happening to my bones?” You can pick up any topic you want and look up the stage of menopause and what’s happening with that particular symptom, and why it’s happening, and then what you can do about it.  So, you don’t have to sit down and read it cover to cover. It’s a reference book.

Dr. Weitz:           Thank you, Dr. Gersh. How can listeners and viewers get a hold of you? Where can they buy the book?

Dr. Gersh:           It’s on Amazon. I’m actually in one of my exam rooms, so you can find me in my office pretty much every day.

Dr. Weitz:           Is the book available on other booksellers?

Dr. Gersh:           It should be, but right now, as you probably know, there’s a supply chain problem. I think they’re actually having trouble printing books. Isn’t that amazing?  So right now, it’s just on Amazon, because it’s just hard to get printers to print books. So we’re just limiting it to Amazon for right now. That’s what the publisher said anyway. I go with what they tell me.  My office is in Irvine, sunny southern, usually sunny. It’s a little cloudy today. We need some rain anyway. Southern California. I can do some telemedicine. I can do telemedicine throughout all of California. For people in other states, now that things are changing, I do have to see people once a year in person. Unfortunately, that’s the crazy laws that we have. But I can do other stuff remotely and usually we can manage, because it’s a great place to have a vacation to.

Dr. Weitz:            There you go. Thank you, Dr. Gersh.



Dr. Weitz:            Thank you for making it all the way through this episode of the Rational Wellness podcast. If you enjoyed this podcast, please go to Apple Podcast and give us a five star rating and review. That way, more people will be able to find this Rational Wellness podcast when they’re searching for health podcasts.

I wanted to let everybody know that I do now have a few openings for new nutritional consultations for patients at my Santa Monica Weitz Sports Chiropractic and Nutrition Clinic. So, if you’re interested, please call my office. (310) 395-3111 and sign up for one of the few remaining slots for a comprehensive nutritional consultation with Dr. Ben Weitz. Thank you and see you next week.


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