The Health Revival Show, Episode 3 — hosted by Becca Chilczenkowski (@thehormonequeen) and Liz Roman (@thepoopqueen) of FitMom. The three A's of HRT: Assess, Adapt, Adjust.

Episode transcript

Why do so many women feel worse after starting HRT?

0:00 Becca: A lot of people blame hormones for what symptoms they develop all of a sudden when they go on HRT. When in reality, the hormone was the testing. It was like, hey, your gut actually isn't as optimal as you think it is. Hey, your liver and your gallbladder aren't working as well as you thought they were. Women are reaching out to me and my doctor didn't run labs. The female doctor that spoke after me at the event, the other weekend, she said, I don't run labs. Throw HRT into a body. You have no idea how they're functioning. Gain 15 pounds. Deal with bleeding. Deal with bloating. Deal with bigger GI problems and now you have to backtrack for multiple months because of a problem that possibly could have been avoided. Hormones are also only as good as the environment they go into. Welcome back to the Health Revival Show. We are talking all things getting ready for HRT, because I think it's a step that is not often considered. And I'm seeing this more and more. Maybe it's because of the space I'm in on social media, but like women are reaching out to me and my doctor didn't run labs. And then actually the female doctor that spoke after me at the event the other weekend, she said, I don't run labs and I'm like, okay, different thought processes and I get where she's coming from in terms of like, you go off of symptoms. Yes. And also we want to know the state of the body before someone goes on hormones. Like I want to know is the are the problems that you are having hormone related or are they maybe metabolic related, inflammatory related, GI related, detox related. Right. Because there's so many other factors that affect how your hormones behave in our experience, and it's much easier to resolve a system slowly. Go on HRT and see how someone tolerates it versus throw HRT into a body. You have no idea how they're functioning. Gain 15 pounds, deal with bleeding. Deal with bloating. Deal with bigger GI problems and now you have to backtrack for multiple months because of a problem that possibly could have been avoided. So this is a big area I am very passionate about. So yeah, we're going to dive into it today. We have three A's.

What should you test before going on HRT?

1:57 Becca: We have the three A's of HRT that we want to evaluate. And the first one is assess. And this is the chunk of it. This is like this is where you need to do the work because it will save you on the back end. It is investing to get a better outcome. But people are too impatient. So a lot of people don't do it.

2:18 Liz: Oh, and it's really silly. I mean, I understand that hormones are fluctuating. They pulse. I can understand the methodology of I want to go help the person optimize, but at the same time, that doctor is going to say, well, if I, you know, give you hormones and then I check your labs and it's too high, I'm going to pull your hormones down. So that doesn't really make sense either. Right. But when we're assessing things we want to look at, as Becca already mentioned, the state of the body. What are your inflammatory markers? What are your blood sugar markers, your insulin, liver, your lipids, all of those things. Because if you are going to put hormones into a body that's already struggling and inflamed, it can backfire very quickly, as you, you know, already alluded to here. But we see this in regards to bloating, water retention, feeling, you know, more constipated for some individuals, maybe acid reflux for some individuals. And insomnia can pop up. Right. Just because we think progesterone should be calming and balancing sometimes. That's not how it works for that individual. And it's disrupting their sleep and just regulating, you know, other things. And so it's really wise, especially when you're getting to the point where you're considering estrogen or even testosterone filtering into estrogen that you also understand your detox pathways and your gut microbiome, as well as your thyroid health, because high estrogen can often damper your thyroid and vice versa. And so this is just the basics that we would look at. And we have a free guide that you can get in the show notes if you want. We give you all of the markers that you can ask your doctor to run again. If they say they're not going to run it for you because you're a cycling female and there's no reason for us to look at your hormones yet, then come into FitMom. We offer the comprehensive bloodwork and review that includes your hormones. If you're curious about where you're at in menopause, we can always add on your FSH and your LA to kind of look at that as well, because I know some women can have lower hormones and still be cycling and feel better if we got their hormones back up to an optimal level while they were still cycling.

Is it perimenopause — or are you just depleted?

4:18 Liz: So you don't have to live with feeling like this is just aging. This is just part of the process. It's just perimenopause. Like, I was thinking about this this morning because as you all know, if you listen to the health revival show back on, I have a lot on our plates. And last night I was doing my face routine. It was late, much later than I typically work on the computer, and I was tired. So I'm washing my face and brushing my teeth. Oh darn, my toothbrush is dead all right. Do I remember where you put the toothbrush charger? I found it great. I plugged it into the wall. I didn't put the freaking toothbrush on the toothbrush charger. So this morning, it was still dead, right. So there's things that you're starting to notice, like, okay, we're entering almost that late 38. You know, we just turned 38 is the 30s. And here's what everybody talks about. But is it really or is it the fact that I'm tired I'm stressed. I probably didn't eat enough that day and I have too many things on my plate. And so I'm kind of doing this to myself. Or is it a true manifestation of brain fog? I can't remember words. I don't know why I went into rooms I can't remember, you know, things about my kids and their sports and whatnot. So there's a difference, I think, to to understand like an acute symptom versus, oh, I'm noticing this is actually getting worse. And your labs can catch a lot of that before it turns into full on dysfunction or disease. We can see and catch various nutrient deficiencies that can really help you when you're in high stress time with your blood sugar regulation. And of course, do a lot with the dietary side. So we want to assess those things. I think it's wise, like you said, Becca, this is an investment to me.

Why does ferritin matter so much for tired women?

5:49 Liz: It's a non-negotiable. I also think from the iron panel and the ferritin, what are we seeing right now? So many women walking around with their hair falling out. They're exhausted and they've never had their ferritin checked. They've maybe looked at iron if they're lucky. But ferritin, we also just saw this this past week a lot in the news. We didn't talk about in the news segment, but they bumped ferritin up from 15 to 30 to be officially anemic. They're giving some other caveats with I appreciate if you're a cycling female, they want you above 50. We would still argue that we would want to see you if you're a cycling female, somewhere around 80 to 90, because ferritin is so important.

Editor's note: the 2026 American Society of Hematology update raised the ferritin cutoff for diagnosing iron deficiency (not anemia) from 15 to 30 ng/mL. Audio left as recorded.

6:08 Liz: But truly, I believe not just looking at one, looking at the whole panel, looking at your iron, your binding capacity, your saturation is also important because if your ferritin is high, this can indicate inflammation. And if your ferritin is low, but your binding capacity is also low and your saturation is high. It's telling us that your liver is producing an enzyme called hepcidin that is going to lock up your iron. So you've got a doctor who's not looking at that full panel giving somebody oral iron who's that's harsh on, you know, digestion and constipation. And they're not recognizing that there's a reason why the body is locking this up. And the same thing can happen with your hormones. Sex hormone binding globulin. Right. If you don't know that going in and you start taking a bunch of hormones and you're not looking at how I need to support maybe with boron or other things, then you're still not going to get the most out of your hormones. So do that work upfront. Assess it. Look at your digestion. I know that we've talked about this before too, but your liver packages up your estrogen. It's got to go to the gut if your estrobolome is off. If you have an enzyme reactivating estrogen and letting it run freely in the body, going back to the liver, that's going to burden your liver. And then if you're not pooping every day, you're not detoxing. And so a lot of that can result in bloating, dysbiosis in the gut microbiome. We see when estrogen is low that impairs our mucosal lining. It also, you know, has a lot to do with maybe butyrate not being produced enough. And there's oral intolerances to food. So I think it's wise to get eyes on at least the comprehensive panel and do that review with us because we can allow or we can discuss the patterns and trends of this points towards digestive dysfunction, low stomach acid nutrient deficiency, a lot of the foundational things that we can do to prime your body.

Why are hormones called stress testers?

8:15 Becca: Yeah, because at the end of the day, I always say hormones are more influencers. They're kind of stress testers of the system. And so especially if you're going to be bringing in exaggerated levels of hormones through HRT, you're basically adding a load to the body that it now has to. But hormones get used, they have to get processed, they have to get metabolized, they have to get broken down, they have to get cleared. Like there is a lot that you're adding to a system that might already be kind of fragile to begin with. And so a lot of people blame hormones for what symptoms they develop. All of a sudden when they go on HRT, when in reality the hormone was really just kind of the testing. It was like, hey, your gut actually isn't as optimal as you think it is. Hey, your liver and your gallbladder aren't working as well as you thought they were. You just didn't have anything that they were really processing and a decent amount. And so hormones are also only as good as the environment they go into. They're messengers, right? They're kind of chemical messengers. And so if you don't have a good stage set, they're not going to be able to do the job that they should be doing. They can't optimize you. Right. We want hormones to optimize. We don't want them to be a burden. We don't want you to feel nothing on them. Right. Like we want them to do good for you. That's the whole point. And so I think at a very minimum, prior to going on hormones, we need to test the sex hormones. Sure, estrogen and progesterone are going to vary, but testosterone won't vary that much. And DHEA is also probably not going to vary very much. And so I want to get eyes on those because that is often where we start. At SHBG. Do you have high levels of SHBG to where like we're going to go on hormones and you probably won't even experience them very much because your SHBG is at 120 because you don't eat enough or you're on a GLP, or you're dealing with other issues that, you know, with the liver or whatever might be going on, or it's too low. And then we know that there's probably cardiovascular issues going on or metabolic issues going on. We want thyroid levels because if you don't have adequate thyroid, thyroid is going to be affecting how your tissues actually experience the sex hormones. Right. And so if your metabolism is not up to snuff, you're going to be putting something into a body that it's like trying to rev an engine that has no gas in it. Right? You're going to basically break down somewhere else because the thyroid is not there to support it. A1c and fasting insulin if you're inflamed. We all know at this point hopefully that metabolic issues are an inflammatory problem. They're not an insulin or a blood sugar problem. Those are just a byproduct. Right. And so we know when metabolic issues are present there's inflammatory issues. Lipid panel CMP CBC was just talked about a bunch of things that can be going on a CBC. If you know how to read, it can tell you a lot about your gut health, a CMP, if you know how to read it, can tell you a lot about your detoxification capacity. So we want at least a minimum of those things. And then, you know, if money is no problem, I'd love to be getting a stool test. I'd love to be getting a DUTCH test. Advanced lipid panel like iron and ferritin should be in there ideally. And so we want to look at as much as possible because serum can only show you so much. Right. And if we're really trying to optimize that's what we run with most of our clients.

How does your gut affect your hormones?

11:08 Becca: We're getting dry stool testing. If we need to. We'll get advanced lipid testing, we'll get DUTCH testing. But all of those things can help get us insight into understanding what needs to be optimized. And then when we get there, there's typically three buckets that this falls into. Like the three systems that need the most support are digestion, detoxification, and metabolism. So when it comes to digestion, you look at the CBC, you look at the iron and ferritin levels, you look at GI stool testing, right? Or you go off of your symptoms. Are you dealing with bloating and gas? Are you dealing with food sensitivities? Do you have constipation, reflux, undigested food in stool? Right. All of these things indicate that different things are probably not processing how they should be in terms of your digestive capacity and your ability to break down and clear things right. Hormones get essentially eliminated from the body via bile that has to go into the stool and be eliminated via stool. And so if you are having undigested food in stool, we know that we're not breaking down things very well. We can trace that back a lot of times to stomach acid or microbiome imbalances, right? Mainly stomach acid if you're constipated, we know that there's probably some issues with bile and gallbladder function. And so then we aren't going to be clearing things as well. And estrogen then gets recirculated. And that creates a whole other host of problems. Right. If you're dealing with a bunch of histamine issues, we know that the mucosal layer and the gut's probably broken down because that's where DAO is produced. The main enzyme that breaks down histamine in the gut and has a systemic effect as well. So like there's so many things that stem from the gut that can then go and effect hormones. So we need to start there. Because as Hippocrates says, all disease begins in the gut, right? That is where we have to look first, because it will affect all of the areas of this that we're going to be getting into. So I'll let you finish that one up in terms of what you would recommend. But yeah, digestion first.

12:55 Liz: Yeah. So I always say this. He says that all disease begins in the gut. The thing is it doesn't stay in the gut. And we know this to be true because lipopolysaccharide these we call it endotoxemia. But these are little antennas that break away from bacteria and they seep out into the bloodstream if we have a leaky gut. So we have to start by supporting that gut lining and the integrity. Because as we've already mentioned and alluded to, when estrogen gets low, that is going to impact our mucosal barrier. So I'm a big fan of things like immunoglobulins. ImmunoLin is kind of the patented dairy free version. This is a bit different than colostrum. So don't get them confused here. But I like ImmunoLin. And I also like tributyrin. Or at least some level of a short chain. Fatty acids supports depending upon where you're at with your digestion. Maybe you don't tolerate it very well in the beginning, and you need to wait until a later stage after you've done some of the kind of cleanup work to incorporate that, or you just have to go really low and slow. I explain to my clients, a lot of times when we are seeding the gut, we are bringing in the good, the bad guys don't love that so much, right? They get a little angry. They they don't want to leave. So they give a little bit of that feedback. Just go low and slow, right? There's no timeline to this, but however long it takes, work your way up to an appropriate dose for you that helps you have oral tolerance. You're breaking down different carbohydrates, fibers, sugars, things that you should be able to have with your diverse diet. And this would apply to different types of fiber as well. I have a whole fiber guide on that and what types and where they ferment in the gut and on yada yada. But don't shy away from these things. If you notice that there's a bit of a reaction, right? I'm a little more bloated or gassy. Just slow down. Go one every 3 or 4 days, you know, then work that in one every other day, then maybe one every day, then walk it up from there. Of course, you should speak with your provider and do this in the right stage. Stomach acid. We can't go wrong with this. This is north to south digestion. I talk about this all the time. HCl support you can do that orally. You can use apple cider vinegar. You can use other stimulants like bitters and whatnot. But this is really, really important. This drops with age with high stress even in pregnancy right when the demands are higher. So really thinking about how you can support that. And if you are on a PPI, you would want to work with somebody to wean off of that. If you have active heartburn or reflux, you would want to get to a place where you have no symptoms for about two weeks before you bring in a betaine HCl support. There's a variety of things I talk about in the Heartburn Healing Solutions course, which is housed in our FitMom Society, so you're welcome to go there seven days free access and go through that if that applies to you. And then last but not least, we always want to be thinking about, especially if you are seeing food in your stool. Is Becca mentioned or fat in your stool? How are we supporting the pancreas and our liver and gallbladder? If you don't have a gallbladder, that's a different story. But digestive enzymes that could be in the form of digestive bitters. For me personally, I don't like alcohol based supplements, so that's not a way that I go. It just doesn't taste great and therefore I'm not going to be consistent with it. So I go with an oral capsule that I can take with my meals. I might walk it up if I'm going out to eat, having a larger meal, and then I will support my liver gallbladder with some bile support, either fat digest or modal clear that can help us break down those healthy fats and be able to absorb all of the fat soluble nutrients and vitamins. I see this a lot too. For people who are taking oral that soluble vitamins and their labs are still low, it is because you're not absorbing it. So you need to be thinking about that digestive capacity and then this overall, you know, this kind of trifecta that I just talked about covers a lot of bases. It covers insufficiencies. It covers helping with infection because you're going to crowd out some of the bad guys and it will help lower inflammation. So that's a really great trifecta to kind of start with. There are a variety of products out there. We use a lot of different brands. We're working on formulating some for our brand with the things that we know we really like. And so it can be a comprehensive product, but if you have any particular questions you can always reach on Instagram. We can share, you know, a little bit more. There's a variety of things in our Fullscript too, and links are in the show. Notes.

How do you know if your liver can handle HRT?

17:08 Becca: So the next system is detoxification, right. And this one can be tricky because unless there's like acute issues going on in terms of like liver cell damage, it probably isn't going to show on your liver enzymes. Like we always say, once liver enzymes become elevated, you're probably dealing with like 50 to 60% function or less of your liver to where a number of liver cells have been damaged. GGT is also something that we'll look at. So when GGT is below a like 12 to 15, we're looking at need for glutathione and low glutathione turnover. When it's elevated we're looking more like a fatty liver indication. And liver is kind of struggling to function. And then I think homocysteine is a really underrated marker for detoxification capacity. A lot of people look at it for like inflammation cardiovascular wise. But it lets you know how your methylation system is working, right. And so if it's too low, we're going to need for B vitamins, right, B12, folate and higher levels. If it's too high, you a lot of times you need more like a tri methyl glycine choline. Things are going to be more of like a back end support versus just heavily lowering homocysteine with high doses of B12 and folate. So in terms of symptoms, constipation, obviously if you're not pooping, you're not clearing your toxins, lack of a gallbladder, you're basically some functional in terms your detoxification capacity, because you no longer have the ability to concentrate bile and really excrete it in large doses when it's needed, like in perimenopause or like when you're bringing in higher doses of HRT, right? You need that capacity. And so without it, we need to support it externally. Skin issues I find skin issues are a big detoxification problem and fragrance or like other major sensitivities, you walk into a room and you can't handle, you know, the smell of a perfume or you can't handle. You get a headache as soon as you go into a hotel room, right? Like your load, your toxin load is pretty much capped, and so any little thing is tripping you over the edge. And then I find waking up really groggy, like waking up and your eye under eyes are swollen or dark. Right? You're feeling really inflamed because overnight is when that detoxification is working the hardest ultimately. And so if you're waking up and you're feeling really rough or your blood sugars are really elevated, we know that the liver's not doing what it needs to be doing. Right. And so in terms of supporting liver, there's a lot you can do. I think that, you know some things that we can mentioned. Yes, I love either an Acetylcysteine or glutathione. I own not everyone tolerates them, especially if you have like a sulfur sensitivity or you're dealing with some like major SIBO issues. You might not tolerate those things right away because you don't have the capacity to really get them to the byproducts they need. But then we're like, okay, fiber, milk, thistle teas. There's a lot of other options that we can use to support the liver. I'll let you share your favorites. But like there's so many options, it kind of just depends on the case.

19:52 Liz: You know, I was going to say let's put in the show notes, our guide on this because there's a lot on the liver love side and there's a lot on the bile side I think from again, foundations. This is where I would advise people start, wake up and have some level of a stimulant. So this could be a warm liquid. You could add lemon to that or lime that's more bitter. You can add some salt as well. When you're starting your meals. Think about colors on your plate. Are you just eating a bunch of tan and brown foods? Right? No. We want to see orange, green, purples, deep dark blues, right? All the berries can be very helpful with the different types of fiber. Raw baby carrots are great. Basil seeds are really great for estrogen as well as constipation. A lot more gentle than chia seeds or flax seeds even. I encourage a lot of bitter greens, so this could be a rule. That's my favorite. Get a blend if you want it in there. But you can also do things like dandelion greens or beet greens if there's a smoothie. If you want to veg out there. I do love a good beet juice, so that's very simple to make at home with some green apple, ginger, lemon and beet. Just blend that up and you can have that. Otherwise, if you want to be a lazy girl, you can be like me and order the suit. Jack lemon Ginger pineapple comes in a six pack from Costco, and I drink about half of one every morning. And that works really great for me because I'll put my camu camu in. There are some vitamin C, it's got a little bit of that bitterness and it's going to stimulate and wake my digestive system up. I do my electrolytes and then I have my coffee. So coffee can be helpful. But we don't want to do coffee on an empty stomach.

What happens to estrogen without a gallbladder?

21:25 Liz: So those would be kind of like my top tips if we're going straight from a foundational place. Of course, there's a lot of teas out there, too, that you can look at different blends that have some of these, you know, different types of collagen, Lowes or bitters or the dandelion, the peppermint, the camomile, all of those things. But I think if you don't have a gallbladder and you are really struggling since your gallbladder removal with estrogen dominance, inflammation, metabolic syndrome, you really want to look at what's going on with your liver and look at your bile acids. I would certainly be thinking about every meal supporting, whether that's taurine, choline, you know, ox bile. That would be my preference. If somebody doesn't have a gallbladder and or TUDCA to work on secondary bile acids in the gut. And, you know, don't overlook just because you can live without a gallbladder, it doesn't mean that you are going to be optimized. The research is there. It's very clear what happens without that reservoir of bile and how important that is to clean out your gut. It is a motility stimulant. It is your anti-microbial. So we see a lot of SIBO after gallbladder removals and or the cause of gallbladder removals with constipation and methane, methanogens. And then, you know, thinking to just what the research shows us a lot of liver disease and metabolic disease associated with that gallbladder removal. Yet your doctor for just like forgot to tell you. Or maybe they didn't learn it. I'm not really sure, but I've got a book coming out about that and that's what I'm writing on right now, so I'm pretty passionate about it. I think this is very often overlooked and should be part of every gut protocol. It should be part of every, protocol. When you're doing any kind of detox as well. Just if that's eradication. Right. But long term with out a gallbladder, you want to be supporting that bile flow. Because if not things are going to back up and then you're going to be estrogen dominant and then be trying to combat that with progesterone, which can make you more constipated and cause acid reflux. And then you're like, well, I don't know what happened here. Is it progesterone driven acid reflux? Is it bile acid reflux. Is it histamine reflux. Because my estrogen is all sorts of crazy or is it low stomach acid. So it's really important to understand the person and the individualization that goes into this. But possibly some things that you can do foundationally.

Why won't HRT work with insulin resistance?

23:31 Becca: Yeah. And the last thing with assessment as a metabolic health. Right. Like what are blood sugars looking like. What is your A1c — is it between 4.8 and 5.2. Are we seeing fasting insulin under 6, our triglycerides, you know in an optimal range or on like 50 than 80? Because when you are dealing with insulin resistance, blood sugar swings, one, it's largely going to affect how you manage your hormones. You store estrogen in fat tissue. And so when you are higher body fat or metabolically not in a great place, your hormones are going to affect you differently than someone that is lean, that has sensitive blood sugars, that is active, all of those things. So like this is why you cannot blanket statement hormones. Every system is going to be different how it's experienced. And you can't optimize hormones. And a system that is metabolically broken because when there is insulin resistance going on, guess what? Not only does your cell not listen to insulin, it's not going to listen to a lot of things because it is resistant. It is insensitive, right? That means when sex hormones go and try to dock there, it ain't hearing it much either. And so this is why metabolic function is so huge. And I think probably one of the biggest pieces to a lot of this. And there's simple things you can start with, right. Like eat your protein first, add a meal, eat your fiber first in a meal with the protein, then eat your carbohydrates. We know that that will benefit you in terms of the blood sugar spike that happens afterwards. Go for a ten minute walk after meals. You know. Don't drink too much water prior to meals. Have a little bit of apple cider vinegar or lemon juice in water prior to meals to help with the blood sugar response on the back end. There's a lot of things that can help supplementation wise, honestly, other than a GLP like there ain't a whole lot you can take some inositol, you can take some chromium, you can take even some berberine. I have not clinically see them do a whole lot by themselves. I think it's a lot more around metabolic being impacted by your immune system, by your inflammatory system, by those things that need to be resolved to really, truly fix the blood sugar issue or you know, you're eating like an asshole and not have a great lifestyle. Like, yeah, your changes are probably very obvious at that point. But for those that are eating healthy, that are exercising, that are doing all the right things and their blood sugar is a mess, those people there's usually more something metabolic, being driven by an immune issue, by a gut issue, by something that isn't as obvious. Stress. Right? Major one.

25:52 Liz: I breathe can impact this a lot. It's pretty low out.

Do lean women need a higher HRT dose?

25:56 Becca: Yeah. So I think the metabolic pieces is the last piece that you really have to address and make sure. So those three systems like gut detoxification metabolic and they're all intertwined. Right. And then when you go on HRT the second way is adapt. These last two pieces are really short but adapt to the person. Right. Like what is their health history. What are their genetics. What is their body composition activity level? We already talked about this. If you are leaner, you're going to need a higher dose of hormone because you essentially burn through it faster. Like your your levels are not going to maintain a stability level on the same dose of someone. That's 35% body fat. If you're 18% body fat,, you just do not maintain the levels the same. If you're a super sensitive client, you can barely take supplements. I would not be throwing hormones into the system right away. Like you have to evaluate these things and if their doctor is not going to evaluate them, you have to be aware of them. And you have to be willing to promote for yourself and be empowered in the education.

Why do pellets and big doses backfire?

26:52 Becca: Because I think this piece is a big piece. And then, you know, I'll let you talk through like how we like to low and slow and not just throw in a bunch of hormones. This is why I hate pellets. And I talked about it publicly, and now a bunch of people are mad, but most people are like, yes, this happened to me. This I hated pellets. It totally screwed. me.

27:10 Liz: So and when people get mad about something that is they're they're being dogmatic in a subject that cannot be one way, you know, is one size fits all, because that's a that's a them problem, not a problem. Right. Maybe pellets work for some individuals. Maybe, I don't know, I have yet to see. I had one client that was doing pretty well, but she wasn't feeling really the effects. It was more so like she just wasn't getting much benefit out of it. Right. And I have a friend that is going to her doctor right now and they were giving her this is like the wildest thing, 225mg of progesterone once a month. And I was like, let me guess, you're just like, whew, I'm happy and horny. And two weeks later, you hate your husband. You know what I mean? You don't want to be touched. And so like, yeah, I'm like really moody and cranky too. And I'm like, yeah, because that's a stupid, way to do that. And what would have happened for her too is acne, right? She would get a lot of back acne. And I'm like, well, this is just craziness to I dose it and think that it's just going to like last because you are going to get those effects. The DHT effects, especially at such a high dose. So in regards to low and slow, we believe that you should do one at a time. I like this approach for many things, right? If I'm layering something in for somebody who's really sensitive, I will often say, I want you to do this for three days and let's make sure that nothing really changes. And why three days? Well, number one, your immune system has a response that can be delayed. And so maybe you this could be from a food standpoint to like you reintroduced to food and you felt good with it. But then you went ham. You're like, oh I haven't had dairy in a long time. And so I'm just going to eat all the cheese and all the yogurt, and then your body is like freaking out at you. So then you think, I can't tolerate dairy? But the reality is you needed to reintroduce it more slowly. You needed to pay attention to. Maybe it's a type of yogurt that you can tolerate and others you can't. That's how I am. Maybe it's a cottage cheese that you do well with and others you don't. That's how I am, right? There's different protein and same with whey in that processing and all of that, structures in foods. So this would be the same thing when I'm putting in a product. Right. I want to know for about 72 hours if nothing changed, then we can basically say, okay, she did well with it. I also wouldn't give up too fast if you don't notice anything, you know, it was like I didn't notice anything. It well, yeah, because your body is getting acclimated. Maybe you're just soaking it in like a sponge and you were that kind of, dried out or deficient for it. So low and slow. Generally. This is what we've recommended progesterone for some women in their 30s can be chaste tree that they're going with. And then they're going with a little like oral progesterone or something like that, maybe a cream. And they feel good. And then maybe they notice that's not enough. So they need to go up. They get a compounded prescription or they go to oral micro progesterone with Prometrium, which is 100mg. Why are we like this? And I've experienced it. I've seen clients experience it is that 100mg may be way too strong for you, but as Becca mentioned in the news episode that we did recently, when the FDA gets a hold of things, they kind of standardize dosing. And so we don't have anything less than 100mg as it stands today for oral progesterone. So we've seen all kinds of craziness out there with, oh, take it every other night. And it's like, but progesterone has such a short half. Like, does that even really make sense? And so that would be something where you may need to work with someone on a compounded side to get 50mg or even less than that. So that's what we mean there. And then I would go with testosterone progesterone and testosterone first and then estrogen typically. And I'll let you weigh on this back up. But unless we're seeing consistent low levels of estrogen and this person is a cycling female, typically it's, you know, I want to see what testosterone will do for her and her estradiol. And look at our total estrogens before we put in estradiol or, you know, estrogens. And then I would want to see her FSH should be above 30, maybe even 50. It kind of depends upon, you know, the school of thought there. And I think this is also a case by case. And I see more women do well with injectable estradiol that you can do really low doses with. And maybe some, you know, vaginal estrogen to support those tissues or suppositories. But that's kind of what we mean when we say low and slow. Introduce one thing at a time. Start with a low dose. Ask your doctor if you're going on like an estradiol patch. I want to get progesterone in first 2 to 4 weeks. Maybe then start that patch and start it at a low the lowest dose. You can always go up, but what sucks and we can tell you hundreds of stories is going too high, too fast and people blow up. And then we've got to kind of detox it from their system. And they've lost three months here of time when they were feeling really good, because they have just become an inflamed, watery mess.

Why don't symptoms stop when you stop HRT?

32:07 Becca: Yeah. It sucks. And when you stop the hormones, it doesn't stop. And that's the thing. They're like, well then I, I got all these symptoms when I went on the hormones and then I came off of them and the weight's still there and it's like, yeah, it totally messed with how you, your aldosterone functions and the sodium and water retention and all of these things that don't just like come off when you stop. So I agree, I think that the it's hard. I know the benefit of estrogen for a lot of people. And I want it in sooner than later. But then you have to optimize systems like I have a client right now. She has low estrogen per her last two blood draws like very low, her cycles getting longer and longer right to where like she's having 4050 days sometimes between periods, but she's having headaches. She's having histamine response. So she's having a lot of signs and symptoms that like she's very sensitive to estrogen still. And so I don't want to put in something here even though it might help with some night sweats or whatever it might be. I want to fix the system first and how it's processing and clearing hormones because she's also constipated. She has a bunch of GI issues, so like time in a place, right? And I think you really have to evaluate where's my health out right now? And is this the best time to bring in progesterone or estrogen? And honestly, I used to be super, super hardcore on you have to have progesterone to balance estrogen if you do not have a uterus. I don't believe that anymore because some of these people truly cannot tolerate progesterone. And I have seen it time and time again and they have become so dysregulated mentally in terms of their Gaba and glutamate levels that like even vaginal progesterone, they can't tolerate. So I think you can still optimize with testosterone and estrogen if you keep a lot of other things optimal in terms of their health and their metabolic health, and they're doing all the right things. But yeah, it's it's been really hard because you want them to have that benefit of progesterone. And some people it's just not worth it. Like it completely ruins their mood and their sleep and they turn into a totally different person. So I have changed my opinion on that. Just the more and more I've seen it. And you know, I know you see it too in some of these clients that like you want the optimal, but sometimes the optimal isn't a possibility in some of these cases. So that's what.

34:10 Liz: I'm excited to learn. You know, with Doctor Carrie Jones, we're mentoring with her and very curious. She loves, at least from some of the sessions that I've heard her. You know, speak on pregnenolone, and maybe even some DHEA. In some of those cases where, you know, you can use more calming supports or just chase tree rides, different types of, herbal supports that could be helpful. I think the biggest thing, and I know when we get into the next episode here with Q&A, is really to think about looking at how you're clearing estrogens and make sure that you're supporting that down the proper 2-OH pathway, which is more what we say, like the protective pathway and really methylated and out of your body. If that was, you know, a situation that I was in because I know with unopposed progesterone, I can be at a greater risk if I neglecting that. And then, of course, your metabolic health, because cancer is a metabolic, disease and it is not always estrogens fault. This is one thing I was sharing with a friend of mine who, has the BRCA gene, you know, and, yes, mom sisters, they have cancer. I understand it's very potent in their family. So I don't blame her for, you know, doing what she did. But I was like, your estrogen is, like, nonexistent here, and you're on testosterone. I would be doing a DUTCH test to see how am I clearing this? And then would there be a way for me to support from a longevity standpoint, to help prevent cancer? Because I've also lost two women. Excuse me? Lost one woman and had another recover, from post menopause, breast cancer when estrogen was low.

Why HRT is not set-it-and-forget-it

35:49 Becca: At that point, it's not the estrogen. It is often the metabolic, the inflammation, the. Yes. And speaking of post menopause, this is a last a is a just like when you go on HRT it is not a set it and forget it, especially if you go on HRT earlier on in perimenopause or even later in perimenopause. The dose that you're on at 55 or even 50 will probably change by the time you get to 60 or 65, if you're really trying to optimize things. And so you'd want someone that is going to be evaluating bloodwork, that is going to be evaluating symptoms, that is going to be making sure that you feel good and that things are stable and if needed, increasing dose. Right. Like, hey, you go on a GLP and you lose 30 pounds. Guess what? Your dose is probably going to have to change. So all of those things are not a stagnant or a this is what we do when we stay there. A lot of times, especially in the first few years, there needs to be adjustments made. You need to find your sweet spot. And that's why I like injections. That's why I like you know, creams or things that are much easier to manipulate versus a pellet versus, you know, and get X amount of patches. And then I'm stuck at that dose until I can go to the next type and increase. Right. And so that's just why I like injections more than anything. Because one, it's a much more stable, consistent dose throughout the week. And that's how your body naturally produces hormones. And so you're getting kind of like this pulse versus I'm going to take a huge dose all at once, once a month, which I just really don't understand. Like it's kind of the same methodology as pellets. And even one high dose per week, like you're going to get a lot more side effects that way. And so we want to create the most natural replacement as possible. But that does need to change as you change and as your body changes. So the last piece is just find a provider that is going to evaluate that which is why I love vital like they do bloodwork every three months for the first year with a client and then every six months after that. So really staying on top of it for you know, what we need to optimize for a client is huge. So if you found this helpful, if you liked this episode, please, especially for your friends and perimenopause like share, subscribe, give this podcast to other people so that they can understand what they should be doing before going on HRT and then do the right things for yourself. Find the right providers. Vital medical is our medical team that we love and are so, you know, fond of and they appreciate us and our perspective on our clients. And then we will also link out in the show, notes the guide. We also have a paid guide that is all about the stuff that we just talked about today. So yeah, make sure you do your due diligence, get the blood work, find the right dose, find the right type, and make sure your body is in as good of a place as possible before throwing these into it.

Frequently asked questions

What labs should I get before starting HRT?

FitMom's practitioners want a baseline before any hormone goes in: sex hormones including testosterone, DHEA and SHBG; a full thyroid panel; A1c and fasting insulin; a lipid panel; CMP and CBC; and a full iron panel with ferritin. When budget allows, they add a GI stool test, a DUTCH test and advanced lipids. Serum alone only shows so much — the goal is knowing how the body will process hormones.

Can HRT cause bloating and weight gain?

Yes — and it's usually a processing problem, not a hormone problem. Becca Chilczenkowski of FitMom calls hormones "stress testers": they must be broken down by the liver and cleared through bile and stool. If gut, liver or gallbladder function is already weak, HRT can trigger bloating, water retention, constipation, reflux and weight gain that were waiting underneath. Assessing those systems first can prevent months of backtracking.

Does gut health affect hormone replacement therapy?

Directly. Estrogen is packaged by the liver, sent to the gut in bile, and has to leave in stool. FitMom's practitioners explain that constipation, low stomach acid, or a disrupted estrobolome can let estrogen get reactivated and recirculated, burdening the liver and driving bloating and estrogen-dominance symptoms. That's why FitMom treats digestion — gut lining, stomach acid, and bile flow — as the first system to support before HRT.

What happens to estrogen if you don't have a gallbladder?

Without a gallbladder, bile can't be stored and released in large doses — the exact capacity you need in perimenopause or on HRT. Liz Roman of FitMom notes bile is how hormones are cleared, a motility stimulant and an antimicrobial; when it falls short, estrogen backs up. A 2023 meta-analysis of 27 million people linked gallbladder removal to a 54% higher risk of fatty liver disease. FitMom supports bile flow with every meal.

Why isn't my HRT working if I have insulin resistance?

Because a resistant cell stops listening to more than insulin. Becca Chilczenkowski of FitMom explains that when cells are insulin resistant, sex hormones trying to dock there don't get heard much either — and estrogen is stored in fat tissue, so body composition changes how hormones behave. FitMom's practitioners look for an A1c around 4.8–5.2 and low fasting insulin, and address inflammation and gut drivers of blood sugar first.

Do lean women need a higher HRT dose?

Often, yes. Becca Chilczenkowski of FitMom has found that leaner, active women tend to burn through hormones faster and don't hold stable levels on the same dose as someone carrying more body fat. Health history, genetics, sensitivity and activity level all change the right dose. That's why FitMom's practitioners adapt HRT to the person instead of using one standard dose for every woman.

Why do my symptoms continue after stopping HRT?

Because the damage doesn't switch off with the prescription. FitMom's practitioners see women start too high, too fast, gain weight and water, then stop HRT — and the weight stays. Overdosing can disrupt aldosterone and sodium and water retention, which takes time to rebalance. Starting low, adding one hormone at a time and watching 72 hours before changing anything avoids losing months to an inflamed, puffy reset.

What ferritin level is too low for women?

Lower than most labs flag. In 2026 the American Society of Hematology raised the ferritin cutoff for diagnosing iron deficiency from 15 to 30 ng/mL. FitMom's practitioners go further for cycling women, preferring ferritin around 80–90, and read the full iron panel — iron, binding capacity and saturation — because high ferritin can signal inflammation and some patterns mean the body is locking iron away, not lacking it.

How should you start HRT — all at once or low and slow?

Low and slow. FitMom's practitioners introduce one hormone at a time at the lowest dose and wait about 72 hours before judging a change, because immune responses can be delayed. They typically start progesterone or testosterone before estradiol, and favor delivery methods that are easy to adjust, like injections or creams, over fixed-dose pellets. HRT also isn't set-and-forget: doses should be re-checked with bloodwork as your body changes.

Key terms

HRT (hormone replacement therapy)

Prescribed estrogen, progesterone and/or testosterone used to replace declining hormones in perimenopause and menopause.

SHBG

Sex hormone binding globulin — a liver protein that binds sex hormones. High SHBG can leave less free hormone available; low SHBG often travels with metabolic problems.

Ferritin

Your body's stored iron. Low ferritin drives fatigue and hair loss; high ferritin can signal inflammation.

Hepcidin

A liver hormone that locks iron away during inflammation — why some women don't respond to oral iron.

Estrobolome

The gut bacteria that process estrogen. When it's off, an enzyme (beta-glucuronidase) can reactivate estrogen so it recirculates instead of leaving.

DAO

Diamine oxidase — the main gut enzyme that breaks down histamine, made in the gut lining.

GGT

A liver enzyme. Low values can point to low glutathione turnover; high values can point toward fatty liver.

Homocysteine

A methylation marker — a window into how well your detox pathways are running, not just a heart-risk number.

DUTCH test

Dried urine test that shows hormone levels and how you're metabolizing and clearing them.

A1c & fasting insulin

Blood sugar control over ~3 months and how hard your body works to keep it there — the core metabolic markers before HRT.

Sources

• American Society of Hematology ferritin cutoff update — Michigan Medicine Laboratories (2026)
• Luo et al., Cholecystectomy and risk of liver disease: meta-analysis of 27 million individuals, Int J Surg 2023
• Lyu et al., Gallstone disease, metabolic syndrome and NAFLD: meta-analysis, Front Endocrinol 2022