Full episode transcript

Cold open: is your “normal” estrogen actually optimal?

[0:00]Becca: There's so many people that are on estrogen support and their estrogen is like a 32 and their doctor's like, yeah, this is great. No it's not. That is not an optimal level. You're not going to protect your bones with that level. It's also a huge myth that a lot of people don't realize you need estrogen to activate testosterone. You need them both optimized if you are super deficient in estrogen. And so a lot of people will go on testosterone. Their level will be in 110 and their estrogens at 25. You're not going to have a sex drive with an estrogen that low, but a testosterone that high. The doctor who's saying that normal labs are there maybe isn't really looking for optimal labs.

[0:33]Liz: Hormones do fluctuate. They pulsate. So you could go into the lab at 9 a.m. and your level could be 200, and you could go back at 11 a.m. and it's 50, and then at 1:00, it's 100. Symptoms trump labs. My testosterone was elevated, according to the lab last time, and I was like, great, I don't really care. I'm not having any negative side effects from it. So I'm not going to go by that lab report. I'm going to go off of what makes me feel my best. We should say here, what about your SHBG? It could be high and it could be binding up your testosterone and some of your estrogen. If your SHBG is there, that ain't free for you to utilize. And I don't see a lot of people running SHBG in conventional medicine.

Welcome back: your questions, answered

[1:13]Liz: Welcome back to The Health Revival Show today. We're answering your questions. We have a lot of juicy questions today. So we're going to get through three of them and then break it up into a part two. And if you don't know how to ask a question you can always go on YouTube and watch the videos. Leave a comment there and ask there. You can also watch our Instagram Stories, where we often throw up question boxes. It's fine if you put them in any question box. I did one the other day that was unrelated to hormones or HRT or thyroid whatever, and some really random, questions popped in. I was talking about H. pylori, and that's completely fine with me because I'll just bank them for a podcast like this, or answer them on another day on time that I have.

Hypothyroid, high ferritin and high cholesterol in menopause: where do you start?

[1:55]Liz: So let's kick it off. Number one is I am hypothyroid, high ferritin and high cholesterol. I'm in menopause. Where do you start? And I love this conversation because first of all, it's good that you are aware that you have high ferritin and that you know that you are hypothyroid because many people don't even understand that they are hypothyroid. But here's the thing that I would say, and Becca, maybe, you know, since this is a question that you got, what part of menopause are you in? Do you know, are you in perimenopause? Are you post menopause? Have you had multiple months without a period? Because I think that can definitely help us answer this better for you.

Is high ferritin iron overload or inflammation?

[2:33]Liz: If you are someone who is not menstruating anymore, it's common that we'll see ferritin go up. But if you are somebody who is cycling still regularly in the years of perimenopause, as we would call it, then we would think about inflammation. And is this like an acute phase reaction? And as we're going to talk about, we would want to look at the whole iron panel, not just ferritin. Ferritin is your storage tank, of course. So when that is high we want to understand is this stored iron or is this an acute reactant that is actually coming, from inflammation? Or maybe, you know, a response to an infection. And that's where we would need to see the whole panel to know what we're dealing with. And look at your transferrin saturation. So when we look at high ferritin and high saturation, that is going to point towards a genuine iron overload that needs to be more of like a hemochromatosis workup. You need to be donating blood. You need to be thinking about, you know, limiting your exposure to iron, iron rich foods, potentially putting lactoferrin in that can be very helpful in hemochromatosis cases. So that's important to kind of know more of that full pattern and picture. And we do have a lot in our iron guide that goes through all the different patterns. I don't believe and correct me if I'm wrong, but maybe this is in there, but I believe that this would be a different, pattern than we originally covered because I don't think we have the transferrin saturation in there.

Why low thyroid raises your LDL cholesterol

[3:59]Becca: Yeah, I think it's just high ferritin. And we talk around what that typically is indicative of which is inflammation. Right. So the thing about this too, we don't know where she's at in menopause. We don't know where, like, are you on medication for hypothyroidism? I'm assuming they are. What type of hypothyroid? Is it low T3? Is it high TSH? Are antibodies present? All those things. So like you mentioned, menopause itself will raise ferritin. Once you [stop] menstruating naturally ferritin will rise sometimes 2 to 3 fold. But we think about a lot of other things here too, because for the cholesterol aspect, hypothyroidism will affect LDL because a thyroid hormone will control how many LDL receptors your liver puts on its surface to pull cholesterol out of circulation. So when the thyroid hormone is low, receptor activity drops and LDL backs up in the bloodstream, right. So high cholesterol is not a separate problem typically, unless... is this person on HRT, right? And so if they are not on HRT, I just had this conversation yesterday with a client who is, you know, in her 60s at this point doesn't want to go on HRT.

What happens to cholesterol when estrogen drops

[5:09]Becca: And so we had the conversation. She has high LDL. And we talked about like there is a certain extent to where if you are not going to replenish estrogen in the system, you're going to battle this like because estrogen also affects how sensitive those LDL receptors are. And so we're not going to have the ability to clear lipoproteins as we normally would.

How a slow gut backs up cholesterol and estrogen

[5:30]Becca: And then on top of all of this, hypothyroidism also slows motility. Right. And so then you are not essentially eliminating the estrogen and the cholesterol via the bile that you should be. And so we see an additional reason that these things are backing up. Right. So I look at this is all one problem, which is why I picked this question because I'm like this gives a perfect example of you could very well end up on thyroid medication, a statin and, you know, dealing with giving blood or whatever it might be when this is all probably related back to GI dysfunction, liver dysfunction and some hormone issues, right? Because of those and because of the state of life that you're in with perimenopause, menopause, when you have this GI problem, you are going to not only the liver is going to be stressed out with having to process all of the bacterial byproducts and endotoxins and all of these things, but then also we have another source of inflammation in a chronically irritated GI system. Right? That is kind of low grade, just irritating the immune system. And it's like, hey, I have imbalances, I'm driving up inflammation, and the immune system constantly has to, you know, manage what's happening inside the gut. And so that will drive up ferritin, that will affect motility, that will stress out the thyroid and metabolism. Right. All of these things I think can be really traced back to the gut. And the liver, and the state of life that you're in.

Why is my blood sugar dropping into the 50s after meals?

[6:53]Liz: Yeah. All right. Next question. Test, don't guess. Right. This is like a there's a lot more to look at here. Yeah. Next: low glucose, non-fasting, related to hormonal and gut issues. Low blood sugars like in the 50s. First thing that comes to my mind is oxidative stress. And that you're very deficient in various B vitamins. Specifically here I would say B1, B2 and B6. I would also have to guess if we looked at your cortisol, that's probably tanked. DHEA is probably tanked. You've lost some regulatory abilities. I'd want to know more too, about your fasting history and how much you're eating. I'd want to know how your sleep is. It sounds like, you know, more reactive hypoglycemia here. If you are running this low, that is very dangerous and you need to be worked up for, you know, diabetes and insulin potentially, and all of that. But, as far as, you know, hormonal and gut related, my first thing is that I would be thinking, you aren't clearing things out appropriately, and that's building up a lot of the toxins and which in turn eats up a lot of your vitamins and minerals that's stress on the body. So, yes, I don't know in terms of what your opinion here is because we're just answering these as we go. I would be saying, what's been the precursor here? Right? Because you don't just wake up one day with your blood sugars in the 50s. What does your digestion look like? What is your stress been like? What is your diet been like, your sleep, all of those types of things. Because I think that that is going to be more important than just blanket stating like, oh yeah, this is going to be a SIBO case. We don't know that there's many different factors that could be driving this.

Cortisol: your blood sugar safety net

[8:28]Becca: Yeah, I think you nailed it in terms of like the cortisol aspect. Because if we think about blood sugars, cortisol is what's going to keep things stable. Right. And so when blood sugars drop too low, your body has a safety mechanism in place. Like it will bring cortisol up. It will bring adrenaline up. And that should raise blood sugars. And so if you don't have adequate cortisol, if your cortisol is dysregulated for whatever reason, you're not going to have that mechanism in place and you're going to end up with these really low lows like 50s severe. That's something that you should get worked up regardless. But I also look at hypothyroidism, right? Hypothyroidism is a known trigger for low blood sugars. I would be wondering like do you have digestive issues? Because if food is moving out of the gut too fast, too, you will release too much insulin and then that will cause a crash later on. And so I would be curious, like, when are you experiencing the low blood sugars? Right? Is it a trend at all in terms of what is the meal consist of?

Is a fasting insulin under 3 a good sign?

[9:21]Becca: Are you eating balanced meals or are you eating a bunch of carbs right. You know the under eating piece too. I think that's huge because that will absolutely drive dysregulation over time of your not being able to even release insulin how it's supposed to. I don't like super low insulin. Some people think that under a 3 is fine. I don't want under a three. That I know you're not eating enough. I know you're not eating enough carbohydrates and having the right response to them. And so I think this is really so more so like we need to know more in a case like this of when is it happening? How consistent is it happening? It's not in fasting. So like after meals it's dropping this low. And so there's no way that your system's keeping things stable. And the first place we would be looking is cortisol and insulin versus like your sex hormones. I don't think that those are playing a role here much. I think that we're probably a really depleted system. I'd be curious what health history is, and then go from there, but, yeah, I, I wouldn't be looking to the gut and the hormone piece first unless you're having, like, massive diarrhea or loose stools or like, major gut issues that maybe are contributing. It sounds like you're just really depleted.

[10:30]Liz: Yeah, it's my guess. Definitely more to know there and then just don't overlook B1, B2, B6 and how much they can help regulate blood sugar, especially when cortisol is low. That's just a really overlooked, piece that many people don't talk about. And that would be something I would do.

On progesterone days 15–25: when do you need estrogen?

[10:47]Liz: All right. Taking progesterone day 15 to 25. When will I know that estrogen patch or gel is needed? And, of course, like, well, test, don't guess, what are your symptoms? This is my first go to. Where are you at in the season of life? Like, are we 35 or are we 50? Because I feel like that's going to be quite different. And what have your levels been? And do you have any trends? We like the Mira a lot if you want to check it at home, because again, hormones do fluctuate. They pulsate. So you could go into the lab at 9 a.m. and your level could be 200 and you could go back at 11 a.m. and it's 50, and then at 1:00 it's 100, you know, so if you want to kind of get a trend there to see what your estrogen is, a Mira could be good to use at home. We also really like the DUTCH test we've already talked about, because it's going to show us the metabolite is going to show us your three types of estrogen. You can look at total estrogens on lab work, but that's just kind of a bucket. Doesn't tell you more specifically unless you're running those individually. And this is where I would also be checking your LH and your FSH to consider for a trend with your symptoms. If it would be time for us to go in and support. But I would also say, and I believe Becca would agree here, we would probably go upstream first to your testosterone and support that if you're still a cycling female. But it's very individualized, and I think that we have to know more.

Low estrogen vs. too-high progesterone: the symptoms

[12:11]Becca: Yeah, I would be looking for super low estrogen symptoms that are like consistent, right. You know, night sweats, hot flashes, mood swings, irritability. A lot of times they'll feel more like extreme anxiousness or depression. Headaches, migraines, cycles are getting super long. You have vaginal dryness with sex, right? You're really achy and, like, stiff and dealing with more, like, muscle pain. A lot of times that is related to low estrogen hair loss nails are not as strong. All of those I think of estrogen. So like if you have a lot of those, I would probably be looking into supporting with estrogen. Or if you're experiencing a lot of too high of progesterone symptoms. So like if you're really tired, if you're dealing with water retention or like, you know, just feeling kind of fluffy, constipation, all of those a lot of times can indicate that your progesterone is too high comparatively to estrogen. Now, which I see also happen too much.

The hormone cascade: how testosterone becomes estrogen

[13:07]Liz: Yeah, I think too a lot of what you mentioned can also mimic testosterone, low testosterone levels. Right. And so if you look at, like the whole chain, just if you're, you know, wanting to visualize this, I would go to Google and look up a complete sample report you're going to see, I believe it's page three where it looks at like we call it the cascade, like the waterfall. So at the top you see pregnenolone which is the mother hormone. And then on the left side you're going to see DHEA that filters down into some of your androgens and testosterone. From there you see two little arrows that are called aromatase action. And people don't realize that your estrogen comes from that. And so this is why when we talk about going on testosterone replacement therapy, seeing what's going to happen, are you going to aromatize enough of that to give you relief. Or do we need to add estrogen in with it? I just think there's a lot more, you know, to look at because the symptoms can be coming from testosterone or estrogen in that picture.

When your testosterone dose is wrong despite “good” numbers

[14:04]Liz: Next: signs or symptoms that T is not at the right dose, despite the numbers. I think this is the last one that we can cover here because it's very quick. Then seeing any symptom improvement, and, you know, you say despite the numbers, as we've mentioned before, symptoms trump labs look at trends, look at symptoms and understand that there is no optimal range with LabCorp, technically, because, you know, Becca, you can weigh in on this because I know you talk about this a lot more than I do, but I don't necessarily care that your testosterone is high. My testosterone was elevated. You know, according to the lab last time. And I was like, great. I don't really care because I took my testosterone the day before, not thinking that I was going for labs tomorrow, and I'm not really feeling the full effects that I want from it. I'm not having any negative side effects from it. So I'm not going to go by that lab report. I'm going to go off of what makes me feel my best. And then when I'm feeling my best, I'll check my labs a few times to see what kind of my patterns and my trends are, because there's so many nuances with checking serum labs.

[15:18]Becca: Yeah, I'm sure my testosterone is probably well into the hundreds, if not high one hundreds, and I have zero negative side effects. My sex drive is great. My energy in the gym is great, my muscle mass is great. So it's very person dependent. I know some women that thrive in, like the 300 levels of testosterone. Is it my recommendation? Not always, but there are some women that are totally fine at that level, and so it's very case dependent.

Why estrogen and testosterone have to work together

[15:43]Becca: Also, what is your doctor saying are like normal numbers because there's so many people that are on estrogen support and their estrogen is like a 32 and their doctor is like, yeah, this is great. No it's not that is not an optimal level. You're not going to protect your bones with that level. It's also a huge myth. A lot of people don't realize you need estrogen to activate testosterone. You need them both optimized if you are super deficient in estrogen. And so a lot of people will go on testosterone and their level will be in 110 and their estrogens at 25. You're not going to have a sex drive with an estrogen that low, but a testosterone that high. So like they need to work together in harmony. And I have a feeling that doctor who's saying that normal labs are there maybe isn't really looking for optimal labs. So kind of paradoxically.

SHBG: the marker conventional medicine skips

[16:29]Liz: We should say here, what about your SHBG? It could be high and it could be binding up your testosterone and some of your estrogen. If your SHBG is there, that ain't free for you to utilize. And I don't see a lot of people running SHBG in conventional medicine. So there's that. Test, don't guess. Thank you guys so much for tuning in to today's episode. Share this with a friend. Rate, review, subscribe and we'll be back on the next episode.

Frequently asked questions

Why is my cholesterol high in menopause even though I eat well?

In menopause, cholesterol often rises because clearance breaks down, not because of diet. On The Health Revival Show, FitMom's Becca Chilczenkowski explains that thyroid hormone sets how many LDL receptors the liver makes, estrogen sets how sensitive they are, and slow gut motility stops cholesterol leaving through bile. Lose estrogen, run low on thyroid and back up the gut, and LDL can climb on a clean diet.

Why does hypothyroidism raise cholesterol?

Low thyroid hormone reduces the number of LDL receptors your liver uses to pull cholesterol out of the blood, so LDL backs up in circulation. FitMom practitioner Becca Chilczenkowski points out this is why high cholesterol in a hypothyroid woman is usually not a separate disease. It is a clearance problem, and it often improves when thyroid function is properly assessed and addressed.

Can gut problems cause high cholesterol?

Indirectly, yes. Your body clears excess cholesterol and used estrogen through bile into the stool. FitMom practitioner Becca Chilczenkowski explains that when hypothyroidism or gut dysfunction slows motility, that exit route backs up, so cholesterol and estrogen recirculate instead of leaving. A chronically irritated gut also adds low-grade inflammation that stresses the liver and thyroid, compounding the problem.

Why is my ferritin high after menopause?

Ferritin commonly rises once periods stop because you are no longer losing iron through menstruation; FitMom's Becca Chilczenkowski notes it can roughly double or triple. If you are still cycling, high ferritin points more toward inflammation, because ferritin is also an acute-phase reactant. Either way, FitMom reviews the full iron panel, including transferrin saturation, rather than ferritin alone.

Does high ferritin mean I have too much iron?

Not necessarily. Ferritin is both your iron storage tank and an inflammation marker. FitMom's Liz Roman explains that high ferritin with high transferrin saturation points to genuine iron overload and warrants a hemochromatosis workup, while high ferritin with normal saturation more often signals inflammation, infection or the natural rise after menopause. You need the whole iron panel to tell the difference.

Why does my blood sugar drop into the 50s after eating?

Blood sugar in the 50s after meals usually means your counter-regulation is failing. FitMom practitioner Becca Chilczenkowski explains that cortisol and adrenaline should push glucose back up when it falls; if cortisol is dysregulated, that safety net is gone. Rapid gut transit, under-eating, low thyroid and B-vitamin depletion can all contribute. Readings this low need a proper medical workup.

Is a fasting insulin under 3 a good sign?

Not according to FitMom's practitioners. Low fasting insulin is often praised, but Becca Chilczenkowski says a result under 3 typically tells her a woman is not eating enough, especially enough carbohydrate, and that her insulin response is becoming dysregulated. In someone with post-meal blood sugar crashes, very low insulin is a red flag for a depleted system, not a sign of metabolic health.

How do I know if I need estrogen with my progesterone?

Consistent low-estrogen symptoms are the signal. FitMom's Becca Chilczenkowski looks for night sweats, hot flashes, mood swings, anxiety or depression, headaches or migraines, vaginal dryness, joint and muscle aches, hair loss and weaker nails. Feeling tired, puffy or constipated on progesterone can mean it is too high relative to estrogen. FitMom pairs symptoms with LH, FSH and DUTCH testing before adjusting.

Why isn't my testosterone working on HRT?

Often because estrogen is too low or SHBG is too high. FitMom's Becca Chilczenkowski explains that testosterone and estrogen work together: a woman with testosterone around 110 and estradiol around 25 often still has no sex drive. Liz Roman adds that high SHBG binds testosterone so less is free to use, and conventional medicine rarely tests it. Symptoms and trends matter more than one serum number.

Is an estrogen level of 32 good enough on HRT?

It depends on your symptoms, not the number alone. FitMom's practitioners regularly see women told an estradiol of 32 pg/mL is great who still have hot flashes, low libido and a poor response to testosterone. Research shows even low estradiol levels help preserve bone density, so the case for more is usually symptom relief and hormone balance, judged by how you feel and your trends.

Key terms

LDL receptor

A protein on liver cells that pulls LDL cholesterol out of the bloodstream. Thyroid hormone largely sets how many you make; estrogen affects how responsive they are.

LDL cholesterol

The lipoprotein that carries cholesterol to tissues. It rises when clearance through LDL receptors slows.

Hypothyroidism

Underactive thyroid. Beyond fatigue and weight gain, it slows LDL clearance and gut motility.

TSH, T3 and thyroid antibodies

TSH is the brain’s signal to the thyroid; T3 is the active hormone; antibodies indicate autoimmune thyroid disease such as Hashimoto’s.

Ferritin

Your iron storage protein, and also an acute-phase reactant that rises with inflammation or infection.

Transferrin saturation

The percentage of your iron-transport protein loaded with iron. High ferritin plus high saturation suggests true iron overload.

Hemochromatosis

A condition of excess iron absorption and storage, typically managed with blood donation or phlebotomy.

Lactoferrin

An iron-binding protein sometimes used to help manage iron balance.

Acute-phase reactant

A marker that rises in response to inflammation or infection. Ferritin is one.

Gut motility

How quickly food and waste move through the digestive tract. Slow motility delays the excretion of cholesterol and estrogen.

Bile

Liver-made fluid that carries cholesterol and used hormones into the gut to be eliminated in stool.

Endotoxins

Inflammatory fragments of gut bacteria that the liver must process when the gut barrier is irritated.

Reactive hypoglycemia

Blood sugar that drops too low a few hours after eating, rather than while fasting.

Cortisol

Stress hormone that, among other jobs, raises blood sugar when it falls too low.

DHEA

An adrenal hormone that feeds the production of testosterone and estrogen.

Fasting insulin

Insulin measured after an overnight fast. FitMom’s practitioners treat values under 3 as a possible sign of under-eating.

Estradiol

The main and most potent form of estrogen during the reproductive years, and the form most HRT measures track.

Progesterone

A calming, sleep-supporting hormone. Too much relative to estrogen can cause fatigue, puffiness and constipation.

LH and FSH

Pituitary hormones that signal the ovaries. Rising levels help mark the shift into perimenopause and menopause.

DUTCH test

A dried-urine hormone panel showing hormone metabolites and the three types of estrogen.

Mira

An at-home hormone monitor used to track trends across the cycle.

Pregnenolone

The “mother hormone” at the top of the steroid cascade, made from cholesterol.

Aromatase

The enzyme that converts testosterone into estrogen.

SHBG

Sex hormone-binding globulin. It binds testosterone and estrogen; when high, less hormone is free for your body to use.

Sources

1. Duntas LH. Thyroid disease and lipids. Thyroid. 2002;12(4):287–93. doi.org/10.1089/10507250252949405
2. Duntas LH, Brenta G. A renewed focus on the association between thyroid hormones and lipid metabolism. Front Endocrinol. 2018;9:511. doi.org/10.3389/fendo.2018.00511
3. Ettinger B, et al. Effects of ultralow-dose transdermal estradiol on bone mineral density: a randomized clinical trial. Obstet Gynecol. 2004;104(3):443–51. doi.org/10.1097/01.AOG.0000137833.43248.79
4. DUTCH Test (Precision Analytical), referenced in the episode. dutchtest.com
5. Mira at-home hormone monitor, referenced in the episode. www.miracare.com