Stress Vs. Sex: Battle Of The Hormones Part 1 With Dr. John Kim And Dr. Lauren Lattanza

HHS 44 | Hormones

Are you dedicated to living a healthy and fulfilling life despite life’s unexpected twists and turns? Listen to Dr. John Kim as he shares his knowledge on hormones, stress, sex, and lifestyle. As a pharmacist and specialist in functional medicine, preventative healthcare, and CBD, Dr. Kim is surely the man to trust when it comes to your pharmaceutical and healthcare needs. In this episode, he joins Dr. Lauren Lattanza to explain customized solutions to the health care needs of individuals. Tune in to learn more about taking care of yourself and how functional medicine has been impacting patients’ lives.

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Stress Vs. Sex: Battle Of The Hormones Part 1 With Dr. John Kim And Dr. Lauren Lattanza

I have Dr. John Kim. He is a functional medicine pharmacist, and he has been in clinical practice for several years. He has been a foremost voice in health wellness and preventative medicine. He received his Doctorate in Pharmacy from Rutgers University with high honors and trained in Functional Medicine from the American Academy of Anti-Aging Medicine, AKA A4M, which we know and love. He actively lectures throughout the country and as an influencer within the functional medicine world to educate and empower everyday people to live healthy and fulfilling life. His message, which is a great one, is, “The doctor of the future is you, the patient.” Welcome.

Thank you so much, Dr. Lauren. It is an honor to be on your show.

I’m glad you are here. Our work is cut out for us. I know we have a lot to cover now, and it was hard to narrow it down. Let’s dive right into it. I do foresee a part two in our future. We wanted to talk about hormone therapy, but before we go into a specific topic, tell me a little bit about you and how you got into functional medicine from being trained in pharmacy.

This is a rare part for pharmacists to get into functional medicine. When I was doing my Doctor of Pharmacy degree and my last year of clinical rotation and working in the ER, I saw the same patient that was having to deal with uncontrolled high blood pressure coming in every week. That tipped me off in terms of looking at these things that could be prevented and what value I am giving to her if I end up having to not change her life and not having her come into the ER.

That is the thing that I dive into. I had good mentors along the way, who showed me what root cause medicine was, and what it was called integrative medicine. Now, it’s called functional medicine and utilizes pharmaceuticals but adds in natural and lifestyle changes to enhance the patient’s experience and the resource that they need to get to control the conditions they have.

That’s awesome that you took it on yourself rather than going with the mainstream advice and the standard of care that you recognized that there was room for improvement in the quality of life. Why are you coming back to the emergency department when we know that we can do things in your off hours when you are at home day in and day out to prevent this from happening and recurring?

I graduated back in 2006. In 2005, I still remember studying for a JNC 7 Guideline. That’s the Bible of all Bibles in dealing with hypertension. Even that overall guideline that mentions lifestyle changes from the beginning, we don’t mention that at all. When you have a patient coming to the ER, you know they have issues, to begin with. The entirety of lifestyle changes and other means to control that is never discussed except for increasing the medication or adding additional other types of antihypertensive and getting them out the door. I didn’t find that to be fulfilling at all. I thought that to be broken. You and I could agree at this time that the entirety of medicine, we call it sick care, not healthcare.

That’s the reason why, when much more deeply into functional medicine, look at the root cause and how we end up having to prevent, but also get into patients better within the cellular level. I do end up having to preach a lot about phospholipids, but this is beyond what we could talk about now. That’s one of the things that interest me.

Another thing that interests me is doing hormones. The first thing that I got trained in was doing compounding. Compounded pharmacies are pharmacies that customize medications for patients. We have labs where we achieve make drugs, creams, capsules, and gels. You name it. We ended up having to formulate and get things made based on the doctor’s orders and the lab values that we ended up having to get from doctors with patients. Everything that we make is customized.

Emotional stress is interrelated to gut function.

When I first started doing functional medicine, that’s what I did. I ended up having to consult patients on managing their menopause or andropause and how to get them from point A to point B. Along the way, I did make a lot of mistakes. Those are the things I’m going to be talking about now. Do not make the mistakes that I made as a clinician. How do we get you better without using hormones? There are a lot of things you could do without using hormones to get you better, including adrenal fatigue. We will talk about that. I’m excited to be here.

I have so much respect for compounding pharmacists because you didn’t learn that in traditional pharmacy school.

We do have one semester of compounding lab, but that was not enough. I ended up having to do an externship and additional training after pharmacy school. There was a lot of work to be done. That’s something that interests me. The biggest thing about compounding pharmacy is we think outside the box. We also look at the root cause aspect because we have to customize based on the patient’s problems that we are seeing. We got to be active in our literature, the biochemistry pathway, including some of the pharmaceutical science that we have to use to make those drugs. It’s not a simple thing that we count pills in and get those patients out the door, but we work to that. That’s the reason why compounding pharmacies do well in working with functional medicine doctors.

I have always found compounding pharmacists to be incredibly helpful. You, among others that are here locally in Scottsdale, and it’s because we need to bounce ideas off of each other, “Here’s what the lab value. Here with the cases.” On that note, let’s go into hormones. What are the key hormones that we need to look at, and how do we best test those?

First thing first, we need to test your adrenals. That is a hierarchy of all hormones to be looked at. You are like, “The patient is having menopause symptoms. Why are we looking at adrenals?” The problem is adrenals when your person coming in is completely burnt out. Maybe they have high adrenal stress or adrenal fatigue issues. That level of cortisol you are dealing with can affect all the other hormones within the cholesterol cascade.

When you talk about having high cortisol or even low cortisol, that affects how the progesterone is going to be in your body. Even if you decide to replace the progesterone, there is a certain thing called progesterone steal. When you have a low cortisol level, the body is going to utilize any supplementation of progesterone to convert that into cortisol because that’s the first thing the body has to support in dealing with the stress that you are dealing with.

Anything that we have to look at, I always say, “I don’t care what you are dealing with. You got to have to address the adrenals.” When you are following adrenal, I mention the lifestyle changes. You have to look at the stress response. You have to look at the sleep. Maybe your gut function is completely off. That also affects how your stress management is because dealing with not just mental stress but physical stress and emotional stress are all interrelated to gut function. I like to look at everything beforehand. Followed by progesterone, testosterone, and DHEA. Those are all related to adrenals. The last thing I will probably look at is estrogen.

A lot of times, when you deal with patients having hot flashes, not the reason that they have low estrogen or low estradiol, for that matter, is because they have an imbalance of hormones is one. The second reason that a lot of people have hot flashes is because of changing the level of changes you see with hormones. That’s the reason why having hot flashes. Not because of estrogen deficiency. A lot of times, these patients are estrogen dominant.

HHS 44 | Hormones
Hormones: Compounding pharmacies think outside the box. We also look at the root cause aspect because we have to customize based on the patient’s problems.

Bringing in that stress management, some of it is out of our hands. It’s easy for you and I to sit and say, “You need to work on your stress management. Go and meditate for a couple of hours a day.” It’s like, “Who’s got the time?” Maybe you are caretaking for a loved one. You are moving. You have got a new career change. You have got all of these things. You have to roll with it.

Everybody has to find what works for them in terms of stress management because otherwise, we do wind up in this constant sympathetic overdrive. It has all of these downstream effects because the pathways are interconnected. It’s not going to be, “I’m having trouble sleeping. I’m having loose stool because I’m stressed out.” We got to place all aspects of life.

This is all about the balance. When I say about hormones, it is like a perfect symphony if you are completely balanced. You could have an orchestra and could be talented members of the band. Unfortunately, if a drummer or clarinet player is completely out of sync, it’s going to sound bad. That’s the reason why, when you talk about hormones, you are talking not just estrogen and progesterone. I mentioned to you all that. We haven’t dived into thyroid yet because that’s an even a bigger topic to talk about, but those are all interrelated to how your hormone is going to be in tune and harmony. That’s why I love using analogies. Your hormone balance is like a fine-tuned band or symphony. That perfect pitch is what you want.

If you get the two are blaring over here, it’s not going to work. We got to keep everybody in sync. What are your favorite ways to test? Do you do blood? Do you do urine? Salivary probably varies depending on the hormone, but what are the pros and cons of each?

There are three types of hormones right now that could be utilized. There’s no perfect test out there. Let’s put that on. When I was going through my fellowship training in functional medicine, one of the physicians was up on stage talking about hormones. They said, “Saliva is the easy test you could test for hormones.” It depends on what you are trying to test for. There are also limitations at the same time.

Serum blood testing is the most popular. It is covered through your insurance much more readily. However, there are limitations to that as well. One, you are only looking at the quick frame of that when the hormone was drawn. When you decide to check for testosterone, for instance, you are not going to go to the lab. You are working mid-afternoon. You want to test testosterone in the morning. That’s the ideal spot for it.

Cortisol is never consistent. It always ends up having to go up and down, but you decide to check for cortisol levels in the morning. Looking at that, you are not getting the complete picture of how your stress response is happening. Given the point, serum testing is okay to do, but unfortunately, depending on what you are looking for is limited to the data. The second thing is, serum testing a lot of times, only looks for bound proteins.

Hormones are lipophilic. It ended up having to linger, not just in the blood but also in the tissues and organs. In order for hormones to be transferred around in the blood, you have to have certain protein carriers, albumin, or even sex hormone binding globules, for that matter. Those tend to be less active. You got to have to count for that as well.

Your hormone balance is just like a fine-tuned band. You want the symphony with that perfect pitch.

If you decide to do a blood test testing for testosterone, we are not looking at the total or the free testosterone level. We also have to calculate sex hormone binding globulin into that and look at what the complete testosterone level is going to be. That’s another reason why patients are sometimes underdosed or overdosed on testosterone just by looking at a blood test because you are not looking at the true hormone level within the hormones that are bound and as well as hormones that are in the tissues. Those are the things that you end up having to look at.

The second test is urine testing. It checks for the total level of hormones being produced throughout the day. How cumbersome is that, taking urine around? If you are at home, great, but imagine bringing that gallon jug with your urine going to work and going to that. It’s like, “I got a voice.” That’s much of an inconvenience.

One of the valuable things about urine testing is its checks for hormone metabolites. That’s powerful information about care for patients who have a history of breast cancer running in the family. Maybe they are over-metabolized or under-metabolized. That’s a great way to check for that. By looking at the metabolite, you are also looking at maybe there’s a certain deficiency that’s going on. Maybe they are not clearing that well. There are certain nutrients missing. That could end up having to be a good point to tweak, as well as looking at certain things like aldosterone. It is a good way to check how bad their adrenal functions are because if their adrenal is completely fatigued, their aldosterone level is messed up, and they can’t retain sodium that well. That also affects hydration. Looking at urine is another palpable tool.

This is one test that I prefer doing when I first initially start patients on is because I can get a better picture, and easy to do. I could do that at home. It is using a saliva test. There are companies out there like DUTCH Test or ZRT, those are two popular test companies out there, but I prefer going with the saliva tests. It checks for free levels of hormones.

When you are looking at hormones in the blood, you are looking at hormones that are bound. When you are looking at saliva, it’s free hormones that are roaming around. You look at a better picture, and you end up having to not underestimate how much hormones are shown up, and you see this clinically. When a patient brings up their lab tests, “The Doctor says I’m low in estrogen.” When I’m looking at the saliva test, the estradiol levels are off the roof.

What’s happening there? They are estrogen dominant. Their progesterone level is down the tanks, and that’s a clinical showing of estrogen dominance. You have to approach it much differently. That’s another limitation of where the doctors end up having to prescribe estradiol patches or estradiol tablets and trying a supplement, including Premarin, to fix the hot flashes. There are much more side effects you see because you already have an estrogen-dominant patient, to begin with. You are adding estrogen. They are going to be completely anxious, sometimes weepy. Lack of progesterone can affect their mental health. We will talk about natural progesterone and synthetic progesterone. There’s a humongous difference there. It’s not the same, but natural progesterone provides a calming effect on the brain as well as is apt to induce sleep at the same time.

One of the things about progesterone is that when you ingest natural progesterone by mouth, it converse to seventeen alpha-pregnenolone, which binds to the GABAA receptor. It has a natural calming effect. If I have a patient coming in and they are completely anxious, and we notice that there is high estrogen dominancy going on based on the sample that we collect, what I usually end up with to give these patients are progesterone capsules and holy basil. Those are two great combos that we know how to use.

The last point about this is in saliva tests. We are able to easily collect samples of saliva to check for the change in cortisol levels throughout the day. There are four-point diurnal testing that you do. Let’s say you wake up at 7:00 AM. Within a 30-minute period, you collect your first sample of saliva, and you do it around 12:00 PM, 5:00 PM, and 10:00 PM. You see a nice trend of your cortisol level going up and down, or some people are completely flatlined. Those are severely adrenal fatigue patients, and certain approaches to how you end up managing these patients are completely different.

HHS 44 | Hormones
Hormones: We have to look deeply into functional medicine, the root cause, and how we end up having to prevent, but also get into patients better within the cellular level.

You cannot be adding in adrenal cortex extracts or some other supplements thinking they are going to be fixing these people dealing with adrenal fatigue. The approach has to be gentle with them. They are already burnt out, to begin with. You don’t need to add in additional testosterone. That’s a quick overview of three different tests. The approaches would be different based on the clinical picture.

That was all such valuable information. I want to ask you a little bit in-depth about it. For the serum, you do a blood test on a patient, and maybe they are a prescribed patient. They are getting a cream or oral progesterone. Would you follow up with the same testing only, or would you maybe add an additional one? Maybe you want to see how they are metabolizing that medication that they are on. Would you then add a urine test but pair that with the serum testing so you can follow that original level? How would you do that?

In an ideal situation, I would like to order all labs, but we are also limited in terms of the money that the patient has to spend. Urine testing and saliva tests are not covered by insurance. An average is spending close to $300 for saliva testing to check for four-point diurnal cortisol testing, along with all the sex hormones. When you are dealing with urine testing, that could range between $700 and up, depending on the metabolite you are looking at. You got to be careful in how much the patient is able to spend.

One thing is that if you are a good clinician, you should be able to tell how the patients are dealing based on the symptoms. Symptoms are the biggest clinical picture you are looking at. The biggest issue is a lot of clinicians that only follow numbers. That’s where the downfall comes into play. I assume we were going through pharmacy school. When I was a chief in the psych ward, we had to look at certain levels of blood levels. Also, the clinician that I was working with was a brilliant MD. He’s like, “You have to go based on the patient’s clinical symptoms and what you are seeing. You can’t be following numbers.”

Even thyroid, for that matter. A lot of times, doctors only into looking at TSH. That’s the wrong way to manage thyroid conditions, and you have to look at how the patients are doing, what clinical symptoms, and any changes that are going on and look at the full picture of the thyroid. That’s the reason why you need to go with an experienced clinician and look at these things. Unless they have experience in doing these things, they are bound to make a lot of mistakes.

Here at Natural Heart Doctor, we always say. “Test, don’t guess.” Especially as it relates to cortisol, if you don’t have that four-point salivary test, you have no idea what the cortisol is doing and how the adrenals are responding. Do you have an inverse curve? Are you flatlined across the board? It’s guesswork. Maybe they are taking an adrenal cortex supplement, and it jacks them up even further. I usually suggest we start with blood and the four-point salivary to get a broad picture and go on to the clinical picture.

There’s a certain limitation in dealing with serum when you are using topical hormones because the pharmacokinetic profile and the overall distribution, and what’s happening within the body, are quite different when you are ingesting hormone versus using a topical. This is the mistake that I have seen doctors do.

When you are using a topical hormone, let’s say it’s a topical progesterone cream, for that matter, you are not going to see a level of change that’s going on in the blood. Why? It’s because you have hormones being distributed, the lymphatics and the tissues. That doesn’t mean it’s not working. The distribution is completely different. Versus when you end up having to ingest progesterone capsules that are within the hepatic portal or the blood. It’s different from that.

If you’re a good clinician, you should be able to tell how the patients are dealing based on the symptoms.

When you are using a topical hormone, you’d rather use saliva testing to check for hormones, whereas if you end up on the ingest hormone is best to look at the change in level in the blood. That’s much different. There’s no perfect test out there. The biggest question you got to have to ask is, what are you looking for?

How do people wind up with a hormonal imbalance, to begin with? What happens? Is it that they are deficient and they need to be replaced, or is there a lifestyle factor? Are there dietary components? How do they wind up there?

It is more dealing with environmental issues right now. Stress, you were dealing with BPA and different toxins. That affects how people produce their hormones. You could look at the downward trend of testosterone levels decreasing in guys over the last several years. Now, the guys are producing less. Why? There are a lot more xenoestrogens you are dealing with.

When you are dealing with female patients, what’s happening there is she ends up having to have a poor metabolic function. They are highly much more likely to be estrogen dominant compared to progesterone. There’s a lot more lifestyle and environmental stress. The stress level that people are incurring now versus what it was several years ago is completely different.

Each approach in dealing with hormone replacement therapy has to be individualized. We have to dig in and do the root cause issue dealing with hormones, and I encourage patients to do this. Sometimes, it’s hard for them to understand that, but you may have to do some detox before you start hormones. You are going to have horrible reactions to topical estrogen when you are not able to properly do phase two metabolism.

You got to support the liver. You got to do some detox. You got to be able to produce enough bile and able to get that flowing. I do end up having to sometimes add some supports in there, but all in all, you got to look at everything in doing that. Also, dealing with the fact that everything is affecting in terms of their hypothalamus function. There’s no reason why they are having a deficiency, but in terms of what I explained now, they are all contributing. It’s the fitting entirety of the pie. In terms of percentage, we don’t know, but when you are dealing with a hormone patient, you have got to look at everything.

You are living that lifestyle. You are bringing in these external estrogens that are more potent than your endogenous estrogens. You are having this replacement at the binding sites and poor metabolism. You are re-metabolizing all of these things because you are not getting them out. It’s a closed drainage funnel. It’s a constant onslaught of toxins and chronic stress. Finding the root cause is essential before we dive into the replacement. Maybe you can talk about some of the lifestyle changes that we could do. Be it like, exercise. Do we notice that there are changes in hormones without replacement?

One of the things I forgot to mention is that pharmaceuticals increase hormones. One of the culprits that are happening right now is widely being used, and it’s prescribed way too early in a patient’s life, is birth control pills. That’s something that I completely forgot to mention. That’s the biggest culprit. You are dealing with food. That’s filled with chemicals and on top of growth hormones.

HHS 44 | Hormones
Hormones: Saliva is actually free hormones that are roaming around. You look at a better picture and end up having not to underestimate how much hormones are shown up.

You end up having to see little girls having earlier menstruation that’s happening at the age of 10 or 11. The second sexual characteristics development press. That’s happening a lot quicker. Girls are much heavier. You are dealing with also inflammation. That also affects estrogen metabolism. You are much more likely to produce a higher level of estrone, which is seven times stronger compared to estradiol.

Anyone out there not knowing what I’m talking about, there are three main different types of estrogens out there. One is estradiol, estriol, and estrone. You could look at the entire cholesterol cascade and look at how these types of estrogen are broken down. When you are dealing with estrone, it’s seven times higher activity compared to estradiol. That particular estrone can break into different types of cancer-causing metabolites as well.

That could be pushed based on the stress response, and chemicals, especially BPA, can push that entire metabolism to those cancerous metabolites of estrogen. Estrogen is not the one that’s causing cancer. It is the metabolites that we have to look at. I’m all about feminism. Your choice of making the time in terms of having a child and such. That’s fine but when you are prescribing birth control pills at an early age, let’s say 12 or 13-year-old girls because they are having early signs of PMS issues. It’s a wrong approach to add birth control pills. You are affecting the entirety of their life and the potential matters in terms of giving birth later on and causing prone to dealing with PCOS and metabolic issues.

When you are ingesting estrogen by mouth, it does a lot of negative things. It increases sex hormone binding globulin. It increases thyroid binding globulin. Your thyroid level could be decreased. It affects serotonin levels. It decreases it. Also, increases clotting issues, bilirubin problems, and testosterone levels decrease.

In female patients, when they start taking birth control pills, a lot of them complain of low libido. It is not the issue. The fact that they are having low libido because they are not attracted to their spouse or their boyfriend, whatever. It’s the hormones. Look at birth control pills. It is not helping them at all. You are ruining their life. I see it a lot of times. I have female patients in their 40s. I’m looking at them. They have been on birth control pills for 10 to 15 years. They are having severe hormonal issues. Those patients are hard to fix and get them balanced.

I own a pharmacy. I dispense birth control pills. Am I going to deny you for coming into the pharmacy to get a birth control pill? Absolutely not. I’m going to tell you, that’s going to be a lot of issues taking that, especially if you are a mom coming in and trying to get a birth control pill for an eleven-year-old. Let’s look at the root cause issue. Why are we having that? Is your girl eating hot dogs all the time and Twinkies? Maybe that’s something of an issue. Is the issue overweight? A lot of girls are coming in, and they are overweight. If you are talking about the socioeconomic issues, the inner city girls, a lot more metabolic issues are going on there. They are encouraged to be on birth control pills early on.

Aside from a personal perspective about when to have a baby, not to have a baby, or having that choice, from a pharmaceutical perspective, you are giving your 11, 12, or 13-year-old child hormone replacement therapy. We are altering that symphony from that early age. It’s going to have many downstream effects. Not a lot of which are good if it’s for acne, painful cycles, and so on. I love that you are the gatekeeper for that. It’s like, “Have you stopped using plastics? Have you made some of these lifestyle changes before we jump into that and start altering your pre-teens hormone cascade?” I’m glad that you brought that up.

I didn’t mention the drug-induced nutritional depletion in dealing with birth control pills. You are also depleting folate and B vitamins. You are also talking about depleting magnesium, manganese, vitamin D, and zinc. You’d be wondering why these young girls are depressed. This bigger issue right now is happening, and you decide to give all these chemicals laced medicine, and thinking they are going to able to control human hormones. It’s the wrong way to approach it. It’s atrocious.

Each approach in dealing with hormone replacement therapy has to be individualized.

We talked about lifestyle. That’s a great tangent to have because I have that question often, and I don’t love to be like, “No, don’t do it.” I also want to be like, “No, don’t do it.” It’s a great tangent to have had. I hope that gained some traction. There are non-hormonal birth control options anymore. Talk to your doctor and get some other options.

Women are not going to get pregnant every single day in their cycle. That’s the total lie they end up having to say about it. There’s a certain amount of window you have to cycle, not every single month.

Women are waiting until they are trying to conceive to get off the pill and learn about their cycle. Women should be learning about the cycle and what’s going on throughout the entire 28 roughly days at an early age. As soon as they start having a menstrual cycle, we should be teaching them what the heck is going on. They might be a little bit more cautious in getting on birth control. That would be a good point to talk about the difference between synthetic hormones and bioidentical hormones. What’s the difference between manufacturing and absorption? Tell me your thoughts.

Synthetic hormones versus natural hormones. Natural hormones are bio-identical hormones that you are producing in your body. When you are working with a company, for instance, you 100% end up having to compound or make hormones that are bio-identical and hormones that are natural to you. There’s a way that needs to be synthesized. You need to synthesize. You have to make those naturally identical hormones in the lab.

There are a couple of ways of doing it. One way is to utilize soy. There are plant-based estrogen or hormones that are coming to play. That’s a reason why you don’t want to eat soy too much, especially in guys. Soy, in general, has phytoestrogens that are available there. What chemists will do is take the phytoestrogen and chemically manipulate that into naturally identical hormones. That’s one way of doing it.

The second way is taking yam or sweet potatoes. There are phytoestrogens there as well. You are taking that and having it chemically alter that into all the forms of hormones. There are naturally occurring testosterone, progesterone, estradiol, or estrone that you couldn’t have to get through a chemical company and compounding pharmacies by those raw ingredients end up having to make them in the lab based on your chemistry. That’s the best way to do it.

Is that the only way to get the bioidentical? No, there are manufactured bioidenticals available. When you go to a pharmacy, let’s say you want to get progesterone 100-milligram or 200-milligram capsules. Those are available as natural progesterone. Unfortunately, that particular capsule is filled with peanut oil. If you are allergic to peanut oil, for instance, it’s not the best way to get that replaced. You want to work with a company pharmacy. Company pharmacies are able to customize the actual release mechanism.

Progesterone tends to get metabolized rapidly in the liver. There is only about 10% viability, meaning that if you are ingesting 100 milligrams, there are only 10 milligrams available. However, that makes sense. On a daily basis, you are only making about 10 to 30 milligrams of progesterone anyway. In a woman, that’s perfectly fine. The room of activity, or at least the viability window, is short. It’s about 4 to 6 hours versus if we are able to change the release mechanism using sustainable release formulas, and we are able to control the release mechanism in the lab, you could sustain that to 8 to 10 hours. That could be an ideal point for patients dealing with anxieties throughout the day because their production levels are too low. That’s a good way to do so.

HHS 44 | Hormones
Hormones: If you’re highly inflamed, you’re increasing the level of sex hormone binding globulin. So you have viability. The bioavailable testosterone level is going to be less.

We are able to change into different dose forms like chokies, where you are able to take a little hard tablet, or you could put on your tongue and let the hormone get absorbed through the mucosal route in your mouth or cream that you could apply in the upper arm, in a thigh area, and rob it well. I tend to tell patients to apply the hormones topically in a more muscular area. The thinner the skin, the quicker the absorption of hormones is going to go through. Ideally, you want to have hormone being more cream that depo effect with the muscle. More likely in a thigh or upper arm.

When you are dealing with patients who are higher “adipose tissue level,” hormone levels in terms of how you ended up having to transport that to the skin could be different. Those patients tend to be much harder to control, and the release mechanism could be slow. Those patients could be higher in dealing with hot flashes when they start hormones.

I keep telling the patients, I’m like, “You need to lose weight.” There’s no other better way to talk about it. You got metabolic issues. You are having a lot of absorption issues. These patients are also dealing with thyroid hormone problems. Low thyroid, and low absorption rate in the skin when you are using topical hormones, you got to have to work with them in a lifestyle change, but it’s a huge problem.

Those are available, and other than the manufacturer’s available item is topical estradiol patches and tablets, which I don’t like to give. There are topical estradiol sprays called Evamist, where you could spray the estrogen on the skin and get it on that way. When you talk about guys, there are a lot more options now compared to what it used to be. There are five identical testosterone replacements available now in injectable form or sublingual tablets that could end up having to utilize.

There are gels like angioedema Testim. Those are topical testosterone that’s been being much more readily recognized by urologists and other primary care doctors to replace testosterone. It’s a positive way to do it but is that going to fix everything? No, because what I see is that any of these patients utilizing testosterone is, especially in guys. This is the reason why I mentioned lifestyle changes. There is a certain point they are going to hit a plateau in terms of the effect they are going to get through their testosterone replacement.

Why? It’s because if you are highly inflamed, you are increasing the level of sex hormone binding globulin. Your bioavailable testosterone level is going to be less. When you have high testosterone getting injected, what is also going to do is it’s going to downgrade your testosterone receptors. In a certain place, you may have to have a wash-out period or start a lower dose to get that patient to a certain level that could get a pharmacological effect. What you need to do is you need to shoot that testosterone level even higher, but there’s another issue with increasing testosterone. It increases estrogen to be converted. Those guys can develop something called gynecomastia or man boobs.

They got to be careful with these things, but they are not looking at these things. They are constantly prescribing testosterone. They are constantly utilizing Pregnyl. Now, they end up having to utilize anastrozole, which is an estrogen blocker. I don’t even like that particular drug. It blocks aromatase inhibition permanently. It’s not good to utilize guys. I’m not a big fan of doing that. I don’t even like finasteride. That also causes a blockade in the five alpha-reductase activities at the same time permanently.

You can check the literature now. They are using finasteride topically for hair growth, while that could also be permanently in terms of blocking those pathways. It’s not a good way to utilize these things. There are certain ways of doing that, but they were too quick in terms of prescribing things and not realizing what is the root cause of the issues.

Lifestyle has to be the first foundation in terms of dealing with hormones. Plus, with therapy, it’s like building a house. You need to have a strong foundation, and lifestyle is going to really manage that.

I’m hesitant, and I hope that most would be about prescribing for a patient that’s outright inflamed. Increased adiposity if they are overweight. They have inflammation because they are living a crappy lifestyle. They don’t have any stress management. Their aromatase is going to already be higher as it is. If you continue to give them testosterone, they are going to have more estrogen production from that alone.

If you are not addressing the inflammation that’s already there, it’s not going to help when you think. It’s going to convert more to estrogen. It’s going to increase the SHBG, which is going to bind it up. It’s not going to be utilized by the tissues. You are not going to fix that patient, even if they are thinking, “No, my friend is on testosterone, and he’s feeling excellent.” It’s like, “How does he eat? How does he sleep? Does he get outside in the sun?” All of these things. Maybe that’s a good segue into the lifestyle that we can talk about.

The synthetics are made to be patentable for pharmaceutical companies to get that out there. Even though if you call synthetic progesterone. It is not progesterone. It is called progestin. It has a different profile in dealing with hormone replacement therapy in the body. Progestin or norethindrone causes higher clotting issues. It doesn’t clear out the body quickly. It also causes a lot of issues dealing with liver toxicity. It’s not the best way to do it. I know prescribers end up having to use that to stop bleeding quickly in patients having heavy menstruation bleeding.

There are places utilizing that but not the best way to do so. When you talk about like Plan B, for instance, I have seen girls in college. When I was in pharmacy school, I worked for Rutgers University Pharmacy Department and working as a pharmacy technician. I still remember seeing customers coming in and getting Plan Bs almost every weekend. I was like, “What are you doing?” That’s going to cause a lot of problems.

The progesterone in those Plan Bs is double the dose of what the birth control is going to provide. It doesn’t clear out quickly in the body. You have much more problems balancing out your hormones in your later life. Don’t do that, please. There are better ways to prevent pregnancies and such, but utilizing Plan B every day, every week, or periodically like that is not the best choice to do.

They don’t talk about this these days, but when you are changing, even though a certain synthetic estrogen and a natural estrogen may look alike. When you end up having to change a little bit of substituents or chemical pathways within that particular cholesterol ring, it changes the profound expression of the hormone completely. Even though it may look the same, it may have that cholesterol ring, but when you change a little bit of the hydroxy group here, it’s going to change the entire hormone profile.

This is an issue with big pharma. They think that this is patting it. It may look the same. It’s not the same. That’s the reason why patients are taking Premarin. It’s estrogen coming from a pregnant female horse. It expresses a whole different thing and a higher activity estrogen level. As a result, these patients who are taking Premarin, even though they might be taking it, probably about 80% of them end up having to quit after one year because the side effects are horrendous. I’m not a big fan of it at all. If you get a chance to even utilize the hormones, make sure you work with a compounding pharmacy to customize your hormone therapy based on your chemistry and your needs.

Using bioidenticals, your body knows what to do with that. When they change the structure, it’s a different set of instructions to your body about how to utilize it. What happens downstream? How to clear it? Bioidenticals are far superior. You have fewer symptoms because your body knows how to handle that. It’s identical to what’s going on in the system. Your body knows how to handle what it’s already making. When you put something exogenously, even when it’s higher than the physiologic amount that’s going on in your body, it still does better than it would from an external non-identical source.

HHS 44 | Hormones
Hormones: If you get a chance to even utilize the hormones, make sure you work with a compounding pharmacy to customize your hormone therapy based on your chemistry and needs.


Lifestyle has to be the first foundation in terms of dealing with hormone replacement therapy. It’s like building a house. You need to have a strong foundation, but lifestyle is going to manage that. You have got to sleep and eat well. Patients who are completely vegans don’t do well in balancing hormones. People, you need fat to balance hormones. If you constantly have a vegan diet and think that’s the case, that’s not going to work at all in balancing hormones.

Especially for female patients, you do tend to do much better with a higher fat intake. When we talk about good fats, you need to have the right amount of protein and fat to balance your hormones out and for guys as well. When you talk about toxins like xenoestrogens, you have to look at what cosmetics are might be using, fragrances, certain perfumes, or certain scents you might be smelling. Air fresheners, for that matter. Those are toxic. They are blocking the hormones that can end up having to affect your metabolism, or it ends up having to cause much deeper issues in toxicity in your body. That could also affect how well you are able to balance your hormones.

The more toxins you end up having to keep in your body, especially within the fat cells. People who are bigger tend to hold onto a lot more toxins. I’m not going to be a toxic person. You have more toxins in the body. You got to have to do some detox before you start doing anything, and you tend to do better. I see this all the time, people who are much more fit and have higher muscle mass tend to do better with hormone replacement therapy or little lifestyle tweaking. They do fine. They don’t need hormones. This is a misconception that we all have.

Lifestyle, you got to eat well, sleep well, poop well, and manage your stress well. Looking at these days and that’s going to impact your overall hormones when you start using that, especially the diet as well. With higher protein and fat intake, patients do better in doing hormone balancing. I don’t go with keto per se. I’m not a big fan of keto. You need to have a more balanced approach. I like paleo better in doing that or the Whole30 if you need some guidelines. Do that. That’s much better. It’s cleaner eating.

The next step you want to support is your gut dysbiosis. Everybody has gut dysbiosis. Having poor gut function, especially higher yeast growth, because you took so many antibiotics, for instance. That could also affect how well you are able to metabolize your estrogen, clearing out certain hormones and such. Everything is interrelated in doing that.

When you are eating crappy McDonald’s and all this processed food, your hormone is going to be out of whack. When I first see a patient, one thing that I do is have something called the foundational protocol. That’s what it is, foundational. Set that tone right off the bat. You got to clean your die and have a better life. You need to sleep better.

Breathwork is the biggest thing that I ended up adding in. I do heart coherency breathing or HeartMath. Being that we are in The Healthy Heart Show, our heart has its own intuitive knowledge there. As you tap in, you can do that doing breath boring. You can lower your cortisol level. That’s all documented. Those are things that could impact patients’ lives.

Afterward, in dealing with the hierarchy of hormone replacement therapy, we need to support the adrenal function and how well they are able to take care of the stress. We don’t have time to talk about everything. Hopefully, Dr. Lauren will be able to invite me a second time and talk about this. Utilizing adaptogens or DHA replacement and especially lifestyle and how well you are sleeping. I love utilizing Oura Ring. If you can afford it, get an Oura Ring. Checking your heart rate variability impacts how well your stress hormone is.

Unless you fix a root cause issue, you cannot correct the patient’s hormones that well.

I still am amazed at the amount of information you are able to get by using heart rate variability, HRV. Oura Ring, Whoop, or some other wearable devices are able to check how well you are while resting and what stress you are taking on your heart. That’s valuable information. After that, progesterone replacement and testosterone. Estrogen is relatively that you never have to need it unless the patient has gone through a full hysterectomy that can’t produce anything.

For guys, it’s the same thing, but it’s a lot simpler. Guys tend to do better with lifestyle changes and weight-bearing exercises. We see that. If you are able to do bigger exercises dealing with squats or all along that line, it increases testosterone production. Once you start to lower your body fat percentage, your overall free testosterone increases without doing anything else.

These are documented cases that we already know. However, one of the little tidbits that I mentioned to people. Just because your saliva or blood tests may show high levels of testosterone being produced and thinking that you don’t need any intervention, that shows signs of inflammation. When you have a high testosterone level, you are completely burnt out, and you are overweight is not the fact that you are producing testosterone. You are converting all that testosterone DHEA because of inflammation going on there. That five alpha-reductase enzymes are overactive or work a lot more when you are dealing with inflammation.

That’s a key thing that we have to look at, and I see this all the time when you are running labs. I have a female patient coming in, “I have low libido. I’m completely famished. I can’t do anything.” I see the testosterone levels are off the roof, and the DHT is completely burnt out. The cortisol was almost flatlined and overweight. That’s a sign of inflammation. That’s what’s happening at this point. First thing first is nothing more than working with the adrenals, get lifestyle changes, pointing the right food back in, doing some detox, and exercising. That’s what we have to focus on. It’s not hard. It’s painful when you try to start this first.

It’s easier said than done to make those changes in your diet and lifestyle, but that’s an interesting point. In working on the adrenals, do we see a decrease in the conversion to DHT, the dihydrotestosterone, if we improve the adrenal state?

Adrenals and the amount of fat percent the patient has. Also, the stress in a soft could convert that. The higher conversion of that hormone is happening because of the five alpha-reductase or aromatase activities. This is one of the clinical pros and cons of working with Lyme patients. You can’t get these patients corrected because their overall hypothalamus is completely shut. Unless you fix the root cause issue, you could not correct these patients’ hormones that well. That’s even a deeper dive, not for this episode, but hopefully, if I get back here for the second time.

Anytime I post a question online, like, “What do you want to hear more about?” It’s always hormones. Patients always have hormone questions. I don’t care about your age or your sex. There’s something going on. It’s like, “I think my hormones are off.” What everybody can gain from this is to decrease the inflammation in their body by working on their sleep, their breathing, avoiding synthetic fragrances, working on their healthy gut, and doing a paleo diet. That’s what we are all about. We are always saying, “Eat well, live well, think well.” Start there so that we don’t have to write you a script.

If my patient needs hormone replacement therapy, I will work with a local compounding pharmacist. I don’t get them on what they need to get them feeling better. I will never going to jump the gun and get them on hormone replacement, adrenal replacement, or thyroid replacement unless we have addressed that. I would like to say, “Give me 3 to 6 months of doing the work, taking these suggestions, implementing them into your lifestyle, and see how you feel at the end of that.” Your libido, skin, and bowel movement are going to be better. Your sleep will be improved. All of these things that patients, “I need some extra testosterone.” They are not feeling how they should. It can start from their day-in and day-out activities.

For the preview for guys, especially. Your overall health meter is your erection. If you cannot achieve a proper natural erection on your own, you have some deeper root causes. It’s not just testosterone. It’s vascular issues and circadian problems. Those are things that we have to manage instead of utilizing Viagra or sildenafil for that. I’m thinking that because even taking these PDE5 inhibitors, so-called Viagra or tadalafil. Those are fine. It works right. The problem is there are side effects and vision changes.

A good thing to throw out there also is a precursor erection. First and foremost, it’s like a morning erection. That’s a good barometer in terms of what’s going on systemically. Do you need more nitric oxide? How’s your circulation? Being natural heart doctors, we see a lot of circulatory issues, and by that, it comes erectile issues.

You are dealing with female patients not having proper libido, at least. It could be a crappy marriage. It’s one or baby that may have lost interest. A lot of times, it’s the stress. Stress is a big problem. Undertaking and dealing with family matters, children, work, and everything. I love using analogies. I tell to my patients, “If you are running away from the dinosaur, the last thing you want to do is have sex.”

That is an excellent place for us to put the follow-up, stay tuned. Thank you so much for joining me. This has been an absolute pleasure. Dr. John, tell us where our readers can find out more about you. You are always putting out such awesome information that I continue to share on my platform.

You could reach out to me on Instagram. I’m active there. My Instagram handle is Dr.John.PharmD. My website is

Go give Dr. Kim a follow. Excellent information is always coming out. We will certainly have a part two and learn continually more from you every day. Thank you so much, and I hope you all enjoyed this episode. We will catch you next time.

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About Dr. John Kim

HHS 44 | HormonesDr. John Kim is a  functional medicine pharmacist. He has been in clinical practice for 15 years and he has been a foremost voice in health, wellness, and preventative medicine.  He received his Doctorate in Pharmacy from Rutgers University with High Honors and trained in Functional Medicine from the American Academy of Anti-Aging Medicine (A4M).  He actively lectures throughout the country and is an influencer within the functional medicine world to educate and empower everyday people to live a healthy fulfilling life.  His message is Doctor of the Future is You – the patient.

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