EP 53: How To Optimize Hormone Therapy With Jim Paoletti, BS Pharmacy, FAARFM, FIACP

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Many people are confused about how to balance hormones and are overwhelmed by all the misinformation about bioidentical hormone therapy for both men and women. It’s easy to be confused because the symptoms of an excess hormone can also mimic symptoms of deficiency. Plus, many people are unaware of the role diet and your gut microbiome play in regulating hormones and how nutrient deficiencies and overloads can upset this delicate balance. But understanding these relationships doesn’t have to be so complicated. That’s why I’m honored to have pharmacist and bioidentical hormone expert Jim Paoletti on the show.

Jim Paoletti, B.S. Pharmacy, FAARFM, FIACP is an independent clinical consultant on hormones, nutrition, and wellness. Jim has 40 years of experience with bio-identical hormone therapies in clinical practice, both in retail pharmacy and as a consultant and educator. Jim served previously as Director of Provider Education for ZRT Laboratory, Beaverton, Oregon, and as consultant and Education Director for Professional Compounding Centers of America of Houston, TX.

He is a graduate and former faculty member of the Fellowship of Anti-Aging and Functional Medicine. Jim has lectured extensively and internationally on all aspects of compounding and BHRT to medical practitioners and consumers and has several articles published on BHRT and compounding pharmacy issues. Jim has also published the book A Practitioner’s Guide to Physiologic Bioidentical Hormone Balance.

In this episode, we discuss:

  • Why symptoms alone aren’t enough to assess hormone imbalances and treatment 
  • Why gut and microbiome health is the first step to hormone health
  • What we get wrong about men’s hormonal balances
  • How long-term use of synthetic estrogen impacts the body and why it’s not always a simple switch to bioidenticals
  • What types of testing your provider should use to accurately assess hormone levels

Listen to the podcast here:

Within the below transcript, the bolded text is Samantha Gilbert and the regular text is Jim Paoletti.

How To Optimize Hormone Therapy With Jim Paoletti, BS Pharmacy, FAARFM, FIACP

If you or a loved one are struggling with hormone balance or are overwhelmed with all the misinformation about hormones and bioidentical hormone therapy, this episode was made for you. What I see in my clinic is that many people are confused because symptoms of an excessive hormone can mimic symptoms of deficiency in another. Plus, many people are unaware of the role diet and your gut microbiome play in regulating hormones, and how nutrient deficiencies and overloads can upset this delicate balance. How hormones interact with one another is complex, but understanding these relationships doesn’t have to be, which is why I’m honored to have a pharmacist and bioidentical hormone expert, Jim Paoletti on the show.

Jim Paoletti is an independent clinical consultant on hormones, nutrition, and wellness. He has 40 years of experience with bioidentical hormone therapies and clinical practice both in retail pharmacy and as a consultant and educator. Jim previously served as Director of Provider Education for ZRT Laboratory in Beaverton, Oregon, and is Consultant and Education Director for Professional Compounding Centers of America in Houston, Texas.

He is a graduate and former faculty member of the Fellowship in Anti-Aging and Functional Medicine. Jim has lectured extensively and internationally on all aspects of compounding and bioidentical hormone replacement therapy to medical practitioners and consumers, and has several articles published on BHRT and compounding pharmacy issues, including his book, A Practitioner’s Guide to Physiologic Bioidentical Hormone Balance.

Welcome, Jim. Thanks for joining me. I am so excited to have you on the show.

I’m excited too. Thanks for asking me.

Jim, as you know there’s so much confusion about hormone replacement for both men and women. One of the things I love about your work is that you understand the relationship between all of our hormones and how they interact with one another, which is so important in assessing hormonal needs. More often than not, we see people starting hormone replacement without any testing or guidance, and without any nutritional interventions or looking at the health of their gut microbiome.

In this episode, I want to talk about these relationships so our audience has a better understanding of how hormones function in the body. Before I dive into the meat of our conversation. I’m curious, as a pharmacist, how did you get into functional medicine and more of a holistic way of looking at the body and how hormones impact the body?

I’ve been lucky and blessed. I worked as a consultant for Professional Compounding Centers of America teaching pharmacists how to become compounding pharmacists and supply all their needs. While I was there, I started running educational programs, including the first CME-approved programs on bioidentical hormones in the United States. I got to bring in some of those knowledgeable speakers that I couldn’t possibly find anywhere.

It was my job to moderate those three-day seminars and listen to all those presentations. You can’t help but listen to a doctor’s office presentation on breast cancer twenty times in three years and know it forward and backward. That was a great opportunity. I then met Dr. Pamela Smith at a seminar that we were both participating in. We hit it off well and she became the Director of the Fellowship of Functional Medicine.

When it started up in 2008, she asked me to come and teach compounding to the classes. There are pharmacists teaching hundreds of doctors. It was exciting but I found out they wanted to pay me for it. I said, “Instead of payment, could I take the classes?” Dr. Smith was so excited. She said, “Yes, we would love to have a pharmacist on board here.” I got to sit in on all the functional medicine classes and I did that multiple weekends for the next eight years and learned so much.

I got more excited about all. There’s so much potential out there. As you know, in functional medicine, what’s our basis? Nutrition. That’s how I got to where I am now. At PCC, I became known as a hormone expert because that’s what I was interested in studying. When I learned functional medicine, we started wrapping everything all together and being able to help patients.

Why Testing Before Hormone Therapy is Important

I’m so glad that we have you and your vast knowledge. I appreciate you sharing that with us. I would love it if you could start us off with a discussion about why taking hormones without testing isn’t such a great idea.

If you are just going by symptoms, you’ll get fooled quite often. For example, if you had a whole page of symptoms and I had a patient rate those symptoms, I could pick any symptom on that page and give you at least three endocrine imbalances or inefficiencies that could cause that symptom. Hot flashes in early perimenopause are more common, lack of progesterone which makes the estrogen work, or high cortisol.

EFL 53 | Hormone
Hormone Therapy: Taking hormones without testing is not a great idea. If you are going by symptoms, you’ll be fooled quite often. You need to also test to hone in on the problem.

Men have problems with symptoms of low testosterone. Their testosterone could be fine but if their cortisol is high, their insulin is high, their thyroid is lower or all of the above, that testosterone won’t work. You need to test to hone in on where the problems are. Trust me, I value the symptoms the most. That’s where I start with patients. When I look at the symptoms, I try to figure out where the endocrine problems are before I look at their numbers. You have to correlate the two. You have to know where the problems are or symptoms will fool you.

Well said. I’m so glad you started us off with that because as we’re going to discuss further and which is so brilliantly laid out in your book, the symptoms of excessive hormones can mimic symptoms of deficiency, and how it’s this constellation of how they all work together. There’s so much fear about estrogen or unfounded fear about estrogen. We can get into that as well.

I think the main hormone I see women trying is progesterone. I don’t know if you agree with that. As you said, there are these other interactions and we often can see reactivity because we’re not looking at cortisol and insulin. Also, dietary and nutrient therapy and stress reduction techniques, looking at those things first before starting on cream from your local health food store. Is that something that you see often or have seen often?

Less often than I used to. Progesterone for example. Nowadays, the people that are educating themselves or people that have been educated in functional medicine or bioidentical hormone. You see a lot more natural progesterone use now than you used to, but in conventional medicine, it’s still the same. There’s a growing number of people that are trying to become educated themselves to find out the difference because women are scared.

Women are scared to use hormones because what we have done in American medicine, in my opinion, is we’ve killed women with our improper use of hormones. We are causing the risk with the type of therapies we’ve done. Wrong route of administration, too much hormone, imbalanced hormones, not addressing the other endocrine function. If you do it correctly, you’re going to decrease risk. Cardiovascular events are the number one killer of women over 50 in the United States.

The most protective thing we know per the science is estradiol, but it has to be at the right amount. If you get too much, you lose that protection. Progesterone works with estradiol. It enhances cardiovascular protection and even testosterone. A little bit of testosterone that women have furthers its synergism with those two. If done correctly, the hormones protect you.

Hormone therapy, if done correctly, protects you. Click To Tweet

Especially if they are bioidentical and not equine or synthetic.

I’m only referring to bioidentical hormones. I don’t use any synthetic hormones at all. There’s no reason to.

How Hormone Receptors Become Down-Regulated

I’m so glad you said that as well. In my practice, I’m always looking at nutrient deficiencies and gut microbiome issues because when those things are addressed, when hormones are introduced, they function more optimally. I want people to understand that. That’s another reason why I was so excited to have you on the show is that you understand these relationships. Let’s dive in. How do hormone receptors become down-regulated?

We have built-in protective mechanisms if the brain senses too much hormone activity. As an eighteen-year-old male, one day, I’m a little bit too aggressive. The brain says, “Look at that testosterone, that’s too high.” It’s going to down-regulate my production. There are other mechanisms. With estrogen, quite commonly, if it sees too much proliferation in the main activity of estrogen in the body, it will down-regulate. In other words, it will decrease the number of estrogen receptors.

You need two things for the genomic action of estrogen: estrogen molecule and estrogen receptor. All we’ve looked at for 40 years is how much estrogen is there. If the receptor is not there, it doesn’t matter how much estrogen is there. What regulates the estrogen receptor? Primarily, estrogen and progesterone. That’s what we’ve keyed in the last ten years or so. It’s the balance of hormones that then makes the receptor optimal too as far as function and numbers. If you get too much testosterone, men and women have down-regulation of the testosterone receptor. Too much estrogen, down-regulation of the estrogen receptor. Too much progesterone, down-regulation of the estrogen receptor. That’s the tricky part.

One of the functions of estrogen is to make the progesterone receptor. By down-regulating the estrogen receptor, now estrogen can’t work to make the progesterone receptor. It’s an indirect way of down-regulating progesterone, but if you have too much progesterone in the system, I used to see that people put in 100 milligrams of topical progesterone on women. You get down-regulation on estrogen receptors, so what are your symptoms? Lack of estrogen and lack of progesterone. It gets confusing to doctors as far as, is it excess? Is it insufficient?

Going back to symptoms of excess mimicking deficiency and those relationships. We’re in this area where insulin resistance is also a huge trigger for hormone imbalance, and that can jack up cortisol. How does this cascade affect progesterone and estrogen?

Insulin resistance is a number one disruptor of the endocrine system in a female prior to perimenopausal or before she gets into perimenopause because of its intense and varying productional hormones. It’s a primary cause of PCOS. Insulin resistance is going to throw off your LH-FSH balance, which is now going to throw off your signal to get down on your production of cortisol so your progesterone could go down.

I see that quite common in younger women that are having problems with insulin resistance. They’re lacking progesterone. I see a lot of practitioners give them progesterone. They’re having bad PMS symptoms, so they’re going to give them fish oil, an anti-inflammatory diet, etc. You got to get back to the key source of the problem. I would give her progesterone too for a while but I’m going to say, “Your problem is insulin resistance. If you do not address that, you’re not going to be able to get pregnant in another five years when you want to.”

That’s where the gut microbiome and the diet come into play. For most of the women that I work help with PCOS, whenever I do a GI map on them, I always find SIBO or other pathogens. It’s such a critical component of that disorder that it cannot be overlooked. It shocks me, considering where we are and how much we know, that the birth control pill is generally the first go-to recommendation by a conventional doctor.

Hormone Symptoms Caused by Nutrient Deficiencies and Imbalances

We have some amazing doctors out there. I want our audience to know that I’m not disparaging here, but let’s be honest. The pill suppresses all hormones, that throws another wrench into things and can create more issues. That in and of itself is an endocrine disruptor. I’m glad you brought that up. Since you mentioned PCOS, what are some sex steroid symptoms that can be caused and/or aggravated by nutrient deficiencies and maybe other imbalances like thyroid?

That’s an endless list. When you talk about nutrition, you’re talking about the synthesis of hormones, especially the thyroid. You need certain nutrients and good metabolism. How are you metabolizing the estrogen? Nutrition is important. The receptor function. There are little things like if you’re low on zinc, your testosterone receptor doesn’t respond. If you look at nutrition, it plays a part in every aspect of metabolism, hormones, and the receptor.

We keep talking about the gut. The rule in functional medicine is if you have multiple issues going on in a person, you always start by fixing the gut first. You fix nutrition first. You don’t try to get the hormones to work optimally unless you’ve already fixed the gut or you’re working on fixing the gut and making sure we have good nutritional supplementation that’s needed. Now, the hormones will work.

With hormones, a functional approach is it’s not just having the hormone at the right level. It’s having it optimally functioning. That’s done by what? Being in balance with the other hormones, having good gut health, and fulfilling any nutritional needs. Those are the three things that make the hormone optimal and its function.

I love that term. I want our audience to remember that term and recognize what we tend to call tier-one support, which is focusing on diet and gut microbiome first, then addressing any hormonal irregularities or imbalances. People want to go straight to the sexy stuff. The sexy stuff is all the fancy testing and our beautiful bioidenticals, which I love. If we don’t start at that base level or at that tier-one level, then there can be a lot of side effects. There can be things that mimic deficiency and create so many challenges in that regard.

Common Assumptions About Hormones Debunked

Whenever I start to work with someone new, for example, I have them clean out their pantry. It’s something so simple. Let’s learn how to read labels. Let’s get past the very savvy food marketing, which is more trickery. Let’s look at what really food is, and get that basic. It’s pairing down to that basic level of understanding of what real food is, and how what you choose to eat impacts your body can be so profound. You have so many years of experience here, Jim. What are some common assumptions made by both men and women and maybe some case studies that you’ve worked with that you can share with us?

For males, it’s quite easy. The world assumes that everything that’s wrong with a male is a lack of testosterone. I don’t see them looking at cortisol. I’m sorry, men have cortisol issues. Men have more cortisol issues. Why? It’s because they’re not as good communicators as women. They repress stuff. That repressed stuff and stress add up over time. Cortisol is going to interfere with testosterone. I have seen guys who are stressed out. Their testosterone level is fine. In fact, it’s high normal, but if they have high cortisol all day, testosterone is not going to work.

They’re having erectile dysfunction, low stamina, and decreased muscle size. It’s not due to the lack of testosterone. It’s due to high cortisol. Men have thyroid issues too. It’s not just women that have thyroid issues. If your thyroid is low, testosterone does not work right. Men have insulin resistance. If insulin resistance is high, testosterone is not going to work right. That’s the main problem I see with men. With women, there’s this belief that hormones can be dangerous as we talked about and that we should only use them for women for a number of years. The other belief that drives me crazy that is still being taught to doctors now is that if she doesn’t have a uterus, she doesn’t need progesterone.

I’ve seen that too.

It is propagated by drug manufacturers of progestins or synthetic progesterone. They work like progesterone in the uterus. Outside of the uterus, they produce the exact opposite effect of natural progesterone. They are increasing breast cancer risk. If you go back to a textbook that was referred to as the Bible of Hormones, he explains the action on the proliferation of estrogen and progesterone, antiproliferative action, are exactly the same in your breast tissue as they are in your uterus.

If they cut your uterus out, we’re not going to give you progesterone. What about protecting your breasts from breast cancer? By the way, synthetic progestins increase bone loss. Natural progesterone stimulates bone growth. Do you have bones? Synthetic progestins are neurotoxic. Progesterone is neuroprotective. I’m sorry if she doesn’t have a uterus. If she has breasts, bones, and a brain, she needs natural progesterone.

Amen to that. I’m so glad you said that. That makes me angry this talk about as you get to a certain age, you don’t need hormones anymore, “Don’t worry about it.” We know that the rise in heart disease among women is always higher when hormones are deficient or pretty much gone, bone loss, and all these things that we’re concerned about. Also, the quality of life. Being able to enjoy life from midlife on is so critical.

Here’s one that scares me that we don’t know enough about what we do. It’s not known commonly here in the United States. There is a strong correlation between a lack of estradiol and the increased risk for dementia and Alzheimer’s. My mother had Alzheimer’s. I don’t want anybody to have to go through that. They don’t have to. It’s horrible. When you walk in and your own mother says to you for the first time, “Who are you?” You’ll never forget that.

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Hormone Therapy: There is a strong correlation between a lack of estradiol and the increased risk for dementia and Alzheimer’s.

There are thousands of articles on Pub Med that show that correlation, and lack of estradiol increases risk. We don’t hear about that much in the United States. Why? It’s because we don’t have a drug-manufactured product that imitates the effect of estradiol in the brain. Is that a reason why we shouldn’t address that problem? No. I tell women that are told by their doctor, “You need to stop taking those hormones.” I’ll say, “Right away, you’re increasing your risk for osteopenia, cardiovascular events, Alzheimer’s, and dementia. It’s your choice.”

Thank you for saying that, Jim. How many women have we seen before they get to that point? I agree. It’s heartbreaking. We always want to prevent that as much as possible. How many women do we see that struggle with high anxiety, panic attacks, depression, and things like OCD? I work a lot in the areas of mental health and autism. There’s the biochemistry piece that we’ve been talking about, the nutrient deficiency piece, and the gut microbiome. We always have to be looking at hormones too.

Hormone Therapy: From Synthetic to Bioidentical

It’s so maddening all of the misinformation that’s out there. We’re in the age of so much information available at our fingertips. We can log on and Google any term or phrase, and we get hundreds of hits, but swimming in all of that has made people worse off because you go down this rabbit hole and it’s so confusing. To your point, because of big pharma, we’re not getting accurate data and accurate information. I’m so glad that you brought that up and that we’re having this as a part of our conversation. I’m curious. We’re talking about synthetic equine hormones. I’m wondering what your thoughts are in terms of tips for converting from the synthetic form to the bioidentical form that women and men can consider.

I think the conversion should be done by somebody experienced with this. If a woman has been on conjugated equine estrogen orally for a number of years, things can change in the body. She can down-regulate estrogen receptors or desensitize them to a point where she may not respond to the typical dosage of bioidentical hormones. She’s got a lot of hormones in there that she has been taking for years orally, so her liver has been revved up from metabolizing estrogens.

You put the typical dose of a bioidentical hormone cream onto her skin, she’s going to take it up and spit it out and have the worst hot flashes ever. What you usually have to do is taper down the estrogen she’s on or the oral synthetic or even the oral bioidentical estradiol tablets. Taper her down on that and it can be anywhere from 2 to 8 weeks, everybody is different, then convert her over.

With synthetic progestins, this is the opposite. If she’s sitting in my office, by the time she walked out the door, I want her off the synthetic progestin. I want her to stop and get progesterone if it was possible. That switch should be made immediately. Estrogen, depending upon how long she has been on, what forms she is on, etc., you have to be careful there because you can make her a lot worse doing the conversion over to a physiological dose of bioidentical hormones.

A disclaimer, please don’t try and do this on your own. Work with someone that understands how to do this correctly. Jim, there’s a lot of talk about hormone cycling in menopausal women to bring about a menstrual cycle with hormones, mimicking that optimum monthly hormone rhythm that women have in their 20s and 30s. There are so many different ways to dose hormones but I was curious what your thoughts were about this type of physiologic dosing.

First, I’m going to make a comment on mimicking the optimal monthly hormone rhythm. The rhythm is not what’s optimal. There was one reason for the rhythm of hormones. The up and down of the estrogen-progesterone throughout the follicular and luteal phase. There’s only one reason for that, reproduction. What the science shows is that you can provide protection to the cardiovascular system, the bone, the brain, etc., and control symptoms with a level amount of hormones. You can do the same amount of hormones every day.

EFL 53 | Hormone Therapy
Hormone Therapy: Science shows that you can provide protection to the cardiovascular system, the bone, the brain, etc., and control the symptoms with a level amount of hormones.

You don’t need to create a cycle to get the benefits of hormones. That has been shown. It’s obvious. I talked to a 70-year-old and she asked that same question. I said, “The only reason for cycling is to get pregnant. If you’re not interested in pregnancy at age 70, you have no reason to do that.” We can get the benefits of the hormones fine without creating a cycle. If a woman wants to, that’s fine. I have found that the vast majority of women when they’re done in that cycle, do not want to go back unless you can show them there’s a true benefit, which there isn’t, not health-wise.

Thank you for clearing that up. I know there are a lot of different ways of dosing hormones. It’s interesting what we have available, but it is important to look at the data behind all of these options. With estradiol and estriol, wasn’t that initially an 80/20, and then they found out that a 50/50 dose was better dosing in that regard? Is that accurate?

Yes. I’m the one who started 50/50 dosing years ago. Dr. Jonathan Wright originally used urine testing. He was the one who started the bias formula of 80% estradiol. Other doctors have since said no. They’ve done later and better studies. The percentage of estriol, E3, in the body is 34%. If you wanted to make a true physiological ratio, it will be one-third estriol and two-thirds estradiol.

However, I was working for a compounding pharmacy company at the time. We know that the number one mistake made by doctors, pharmacists, and everybody else is math. You get into a one-third to two-thirds ratio, and then the doctor tests the patient and wants to decrease the estradiol by 10% and increase the estriol by 15%. You’re doing so many different calculations and formulas. My philosophy was let’s keep this simple. Let’s make it 50/50.

That was my creation years ago. When I announced it, pharmacy companies weren’t thrilled with me because they sold all their doctors for five years the 80/20. Now, they’ve got to go back and tell, “No, we’re going to do it differently.” My philosophy is quite simple. Measure both of them. I don’t see that often enough. I see doctors doing follow-up monitoring and that’s about it. You got estradiol in there too. Measure both of them. Keep the two on the range. It’s very important to realize this.

What was wrong, in my opinion, with the 80/20? Estriol can block the effects of estradiol at the receptor. If you have more estriol than you should, it’s going to require more estradiol. More estradiol, more metabolized that can damage DNA. You should always try to find the least amount of estradiol to use in each individual woman that provides the benefits of controlling her symptoms and providing protective benefits. You want to make sure the estriol is not too high too.

I appreciate you clearing that up because there’s a lot of talk about new data that estradiol only is the way to go when dosing.

You have to understand where that data comes from. Who’s propagating those studies? The manufacturers of the estradiol-only patches and tablets. What I do is physiological. Meaning we’re going to imitate the body the best we can. The body produces a certain amount of estriol. It’s a protective hormone. Its endpoint is estrogen so it does not metabolize to any dangerous possible cancer-producing metabolites. Therefore, why would you not want to put that back and mimic the way the body has done it for years?

Hormone Testing Methods

I would love to know, what are your favorite testing methods for testing hormones in men and women?

Probably saliva testing but it has to be through a good lab. I use basically ZRT Laboratories because they have the strongest data supporting the observed ranges. Their ranges are correlated not only to symptom management but to dosage route and time of the last dose of the hormone. They have data that is strong. Saliva will give you a good representation of the free hormone, which means it’s unbound. It can work on receptors.

Serum testing is okay. I use it more for guys, but there are problems with it for women. Most labs still use the same testing procedure that was used to measure testosterone for males. It’s not accurate in females at all. Testosterone serum, most of the time, is worthless in females. You can use it for baseline estrogen progesterone as long as you’re aware of the fact that if you’re in the lower end or upper end of that normal range, which is wide, you’re probably going to have symptoms.

You got to squeeze the range down from the normal to what it should be, and that takes a little experience. You are in serum looking at the whole hormone. You may look at somebody’s, male or female, total testosterone and it looks great, but if they have too much sex hormone binding globulin because they have too much estrogen in their body, then their free testosterone is not going to be high enough. I would much rather look at something that represents the free hormone because that’s the active hormone. It’s bound to a carrier protein. It’s not going to work on the receptor.

I do use urine testing but not for monitoring hormones. I use urine testing a lot for looking at estrogen metabolism. You can metabolize them safely. I’m looking at iodine, other nutrients, and heavy metal testing. When you ask what’s my favorite testing, what am I looking at? For basic hormones, sex steroids, cortisol. Cortisol can be measured in saliva or urine. Saliva is less expensive. Saliva is my go-to for most patients, but if we start talking about other things like other nutrients and heavy metals, then we’re going to urine. I do use capillary blood, a finger prick at home, and the blood drops on a card.

If the patient is using any sublingual therapy, a troche in their mouth with hormones, they can’t use saliva. Maybe you have a patient who has Sjogren’s syndrome that you can’t collect saliva or dry mouth. They can’t get enough saliva. Capillary blood is very good. You are now looking at a whole hormone, so you have to do a sex hormone-binding globulin along with it. To me, it’s a better representation of what’s going on in the body than a typical serum, which is measuring venous blood. Venous blood, let’s put it this way, that’s a source system of your body. Venous blood is getting rid of waste and excess.

Hormones are not drugs. They’re not trying to be cleared as quickly as possible from the body. They can be absorbed across the skin, go to the tissue, go to the receptor to work, and then they’re metabolized. Guess what? They’re not going to show up in a serum. That is probably the most common problem I see now. Doctors are using a patch, cream, or gel, topical application, and trying to monitor using venous serum and conventional testing. It does not work. It’s invalid. It has been proven invalid in a couple of studies.

Hormones are not drugs. They're not going to get cleared as quickly as possible from the body. Click To Tweet

I’m so glad you spoke into that as well because that’s the go-to for most doctors. I think this conversation around testing methods, what can be helpful, what’s not so great, and so forth is incredibly informative and powerful for our readers. What do you wish that men and women would ask about but don’t? What is that one thing that you feel is missing in a patient inquiring about hormones and the need for hormones and so forth?

Can I go off hormones for that?

Of course.

I wish they would ask, “What do I need to do nutritionally to maintain good health?” That’s what I wish because they ask all kinds of questions about hormones and they want to know more information. I wish more people asked that. Sorry, I didn’t answer your question as far as hormones.

EFL 53 | Hormone
Hormone Therapy: People ask all kinds of questions about hormones and want more information instead of asking what they need to do nutritionally to maintain good health.

You did.

It applies to hormones too as we’ve talked about.

I’m glad you said that because I couldn’t agree more. People want to go to the sexy fun stuff. That’s what I call it. That tier-one level of support with changing the diet. That’s boring. I hear “I don’t need to do that” but I have worked with so many men and women over the years where we just make a dietary change and everything gets all balanced out. They feel better. They sleep better. Their digestion is better and it’s truly incredible. These are good basic changes that you can make simply by going to the supermarket and making some wise choices or supporting your local farmer.

I have to say, Samantha, if every one of my patients consulted with you and went through your tier-one support program, you would make my job so much easier. It would be so much more effective so much more quickly that people would be blown away. I worked that type of thing in but they’re here to see me about hormones, the fun sexy stuff. Sometimes it’s hard for me to convince them how important the other stuff is. If you and I were in the same building and they came and saw you, then they came and saw me, we’d be cranking out. Wouldn’t we?

That would be amazing. Bring me over to Ohio and I’ll set up shop there.

We can do it virtually.

That’s true too. That’s the beauty of our world now. The technology aspect is that we can do virtual consultations. I feel virtual is great but to be able to see someone in person and to physically have them in front of you and be able to develop that relationship is a different feel. It makes me sad that that’s gone.

I missed that because sometimes I’ve got women in tears and they’re upset. Sometimes it’s good tears because I’ve told them, “I’m hopeful you can feel better.” Sometimes I want to reach out and put my hand on theirs and comfort them. That’s hard to do virtually. Put your hands up on the screen.

Here’s a big hug. I appreciate that. A big part of what we do is having grace and compassion and understanding for people where they’re at. That’s also missing in medicine. That’s a huge part of healing, just being able to put yourself in someone else’s shoes and understand that it will get better. You’re not going to always be here. That’s something I always want to leave people with and encourage people with, especially our audience. Any final thoughts that you would like to share with us?

The Dangers of Improper Hormone Dosing

We’ve mentioned a couple of times that what I do is a little bit different. I’ve used the word physiologic. I would like to define what I mean to the people here. When I teach doctors, nurses, and pharmacists how to do this, my first lecture is, “You’re not putting a foreign substance in the body. You’re not putting a drug in. It may require a prescription but it is a hormone. If you’re going to put those hormones in, you’ve got to have a target, which is going to be a 20 to 30-year-old. The first thing you have to know is how much of that hormone that average person of this sex produces on their own at that time period. If you do not know how much the average daily production of estradiol in a cycle of a woman aged 25 is, don’t attempt to put estradiol back into the body. It’s the same thing with the other hormones.”

That is physiologic. I’ve always asked this question. Why is it that doctors put into the body more estradiol than a woman ever produced even when she was pregnant? I don’t understand that. Why do they put in more testosterone in guys? You look at AndroGel. The typical dose many doctors start providing is a 25 or 50-milligram dose. When he’s eighteen, a male makes 5 to 6 milligrams daily. Because they’ve tested that in serum, it takes that huge dose to get the serum level up to what a doctor is going to accept as good.

You’re using the wrong testing. You ended up putting in too much hormone. Drug manufacturers have covered this up when they came out with the patches, creams, and gels, they came up with a new word. They say it delivers 5 milligrams of testosterone. Delivers is defined as what they see in conventional serum testing, venous blood, which I’ve already mentioned is invalid. What they did was when AndroGel came out, they go to the doctor and said, “Here’s a great way. We don’t only have to give guys injections.”

The doctor says, “I can use my conventional testing to monitor.” You say, “No, the doctors have to use this new-fangled saliva stuff.” The doctor is going to say, “Get out of my office. I don’t want that.” You’re not going to sell your product. What do they do? They kept using higher doses in their own internal studies as they are developing it until they got the serum level up to where they needed it for the doctor to accept it.

They ended up giving guys 5 to 10 times more testosterone. Guess what happened with those guys? A few months later, their receptors are down-regulated. What does the doctor do? Increase the dose. They finally get up to a point where they’re so high the doctor says, “I can’t raise your dose anymore. In fact, we’re going to quit it for a while.” Now, the guy gets apathetic and depressed. The literature even says, “Testosterone for grown guys can cause suicide.” All because of what? We want to sell a drug product.

That’s heartbreaking. I’ve seen that happen many times. They can’t sleep or function either. It dysregulates everything. I’m so glad that you said that because guys don’t talk about it that much. I want to reach men too. I want men to know that there is a healthy way to do this. Looking at the thyroid, looking at cortisol levels, looking at stress in your life, and how you are eating. We have a saying here, “How are you sleeping, eating, and pooping.” Let’s start there.

I love that. With guys, do you know where I’m going to start? What’s your diet? How many guys are eating well and getting good nutrients? How many guys taking multivitamins? That’s a key starting point for males. Let’s look at your gut and your nutrition, and we’ll look at this other hormone stuff at the same time.

A key starting point for male BHRT is to look at their gut and their nutrition. Click To Tweet

I’m not sure if you see this, but I see a lot of restrictions in men from a dietary perspective because, after 40 to 45, things start to shift. They’re working out twice a day. They are doing cardio in the morning, weights in the evening, and eating 1,500 calories a day. I don’t know how that’s possible in a male but I have seen it. They’re not making any progress and going, “What am I doing wrong? I think I need to restrict myself even more.”

We can go back to these basics and address what kind of deficiency we are looking at. Let’s address that first, and then look at testosterone. For all the guys in the audience or for their wives, we want to make sure that you’re well taken care of too. You matter. Your hormones matter. There’s so much that we can do. I can’t say that enough because we’re so used to talking about women’s hormones. I want to encourage men out there to please don’t let this go too long and feel crappy. It’s not worth it. Thank you again, Jim, so much for your knowledge, your wisdom, and your time. Thank you for blessing us. I am delighted to have you back on the show to talk about thyroid at some point.

That would be fun. I would be happy to do that. I’m very excited to work with you at any time. You did such a great job. Thank you for having me. I enjoyed this.

I trust that my conversation with Jim brought clarity and understanding about hormone function and balance. You have more tools and power than you realize to heal your hormones such as the type and quality of the foods you eat, how you manage stress, the health of your gut microbiome, and even the quality of your relationships. Jim reminds us that hormones done correctly help protect and maintain most systems in the body. You can find Jim’s book A Practitioner’s Guide to Physiologic Bioidentical Hormone Balance on Amazon.

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1 thought on “EP 53: How To Optimize Hormone Therapy With Jim Paoletti, BS Pharmacy, FAARFM, FIACP”

  1. I have a clarifying question. I was prompted to get off of hormone replacement drugs (progesterone, bi-est transdermal cream and DHEA) because of my excess copper issue. I was informed that bio-identical is no different than synthetic and thus foreign to the body. My question after listening to the podcast with Jim Paoletti is should I actually be considering taking a hormone because I’ve developed osteopenia, and I’m concerned about breast cancer since my sister recently had a double mastectomy. This episode was very enlightening and frighting at the same time because of the body changes as we age and a desire to ward off Alzheimer’s as well. Love your podcast!

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