Our hormones are essential to our mental and physical health, yet we often don’t understand (or we minimize) the key role hormones play in fostering our wellbeing. And to make matters worse, many–or dare I say most – medical practitioners are not given adequate training when it comes to understanding the role hormones play in the health of our bones, heart, muscles, and brain. And when our bodily systems are not functioning well – whether we’re experiencing issues such as a lack of focus, sleep disruption, weight gain, or low libido – our mental health can be deeply affected. Today, I’m joined by a top medical expert, Carrie Levine, who will help us discover key components of HRT (hormone replacement therapy) and so much more.

Topics discussed include mental heath, depression, psychotherapy, support, physical health, hormones, HRT, hormone replacement therapy, estrogen, progesterone, progestin, DHEA, HPA Axis, cortisol, stress, stress management, exercise, resistance training, weight training, carbohydrates, protein, testosterone, Women’s Health Initiative, menopause, perimenopause, post-menopause, relationships, A1C, blood glucose, sex, and libido.

Please note that this episode contains sensitive material; listener discretion is advised.

Note: If you or someone you know needs immediate support, please call your emergency services. In the US, 24/7 help is available by calling “911,” “988” (Suicide and Crisis Hotline), or SAMSA (Substance Abuse and Mental Health Services Administration) at 1-800-662-HELP (4357). As applicable, additional resources may be provided in the show notes.

Non-Emergency Online Mental Health Information:

https://www.nami.org/support-education/nami-helpline/

https://odphp.health.gov/myhealthfinder/healthy-living/mental-health-and-relationships

IMPORTANT DISCLAIMER: No expert is offering medical or psychological direction or advice; the content is purely informational in nature. Please consult your physician or healthcare provider before undertaking any new regimen or procedure.

https://www.nami.org/support-education/nami-helpline/

Connect with Dr. Carla Manly:

Website: https://www.drcarlamanly.com

Instagram: https://www.instagram.com/drcarlamanly/

Twitter: https://www.twitter.com/drcarlamanly/

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YouTube: https://www.youtube.com/@dr_carlamanly_imperfect_love

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Books by Dr. Carla Manly:

Joy From Fear: Create the Life of Your Dreams by Making Fear Your Friend 

Date Smart: Transform Your Relationships and Love Fearlessly

Aging Joyfully: A Woman’s Guide to Optimal Health, Relationships, and Fulfillment for Her 50s and Beyond

The Joy of Imperfect Love: The Art of Creating Healthy, Securely Attached Relationships

Imperfect Love Relationship & Oracle Card Deck by Dr. Carla Manly:

Etsy

Amazon

Connect with Carrie:

Website: https://carrielevine.com/

Instagram: https://www.instagram.com/carrielevine.cnm/

Facebook: https://www.facebook.com/CarrieLevine.cnm/

LinkedIn: https://www.linkedin.com/in/carrie-levine-cnm/

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The Art and Science of Boosting Your Health with Hormones and HRT

Boosting Your Physical and Mental Wellbeing with Hormones and HRT

Our hormones are essential to our mental and physical health, yet we often don’t understand or we tend to minimize the key role hormones play in fostering our wellbeing. To make matters worse, many or dare I say most medical practitioners are not given adequate training in the area of our hormones. They don’t understand and therefore can’t help us understand the impact of hormones on our bones, heart, muscles, and brain. When our bodily systems are not functioning well, whether we’re experiencing concerns such as a lack of focus, sleep disruption, weight gain, low libido, or other concerns, our mental health can be deeply affected.

I’m joined by a top medical expert who will help us discover key components of HRT or hormone replacement therapy, and so much more. We’ll focus on this reader’s real-life question. “I’m in my late 50s and suffering from mild depression. I’ve gained a little weight and don’t feel good about myself. My best friend started HRT. She says it’s a game-changer. She said it helps her with issues I’m facing, the low sex drive, gray mood, and interrupted sleep. I have limited finances and wonder if it would be better to put my money into psychotherapy. What do you think?” With that issue as the focus of this episode, I’m Dr. Carla Marie Manly. This is Imperfect Love.

I am joined by a terrific special guest, Carrie Levine. Carrie is a Certified Functional Medicine Practitioner and Author who is the Founder of Whole Woman Health, treats women’s health concerns by incorporating gynecology and functional medicine. Welcome to the show, Carrie. This is your second time on the show. I am so excited to have you with us.

Thank you for having me back. We had a lot to talk about in not enough time last time.

We did. The interview was incredible. I love this question. I want to start it off. For the male audience, this episode is suitable for you. From my perspective, I’d like your thoughts, but it doesn’t matter your gender because we all have hormones in our bodies. We all need some testosterone. We all need some estrogen. It’s not dependent on your gender. You have more of the other.

Our hormones are so critical. For our male audience, they likely have a wife, sister, mother, daughter, or someone who’s impacted. HRT is becoming more common for men. These topics aren’t discussed, so I’d like to keep it as open as possible. Before we do that, what are your thoughts on that type of inclusive conversation?

Hormones are tiny molecules that have a big impact on all people’s bodies, no matter their gender or sex. Nobody gets to escape their influence. I just happen to be much better versed in female body responses to hormones as opposed to male bodies. It is very common that women will ask me at the end of an appointment, “Who can my partner see who’s like you? Do you see men? My partner might benefit from this similar support.” It comes up a lot for sure.

In many ways, I feel like with what’s happening on social media around hormone therapy for women, there still is a huge dearth of information for men. Again, I mean biological sex and not gender. A whole other conversation is the use of hormones for people who are transitioning between worlds. That’s a whole area of specialty that I am not a part of, but there are people in that world who are gifted at what they do.

That is another whole different conversation and a very important conversation. Before we launch into the reader’s question and before I ask you what makes you, you. I want to emphasize that HRT is not estrogen for women and testosterone for men. Many men think, “It’s just about increasing my libido.” It is not just about libido. As the introduction stated, it is your heart health, your bone health, your mental health, and your muscles. These hormones are so essential. It’s only in the last couple of years that I’ve come to pay attention to that.

One of the reasons I get so excited about an episode like this is that even if this generation has missed out in many ways or is coming to things a bit on the slow end where we’ve passed some markers in some ways. At least we can get good, clean, and clear information out to the next generation so that we are no longer in the dark ages from some misinformation and studies, such as the Women’s Health Initiative that were misinterpreted and misunderstood and some bad science.

Carrie Levine’s Specific Focus On Hormonal Care

Before we get into any deeper on it, you could tell I get so excited. Could you tell our audience a little bit about what makes you, you, especially if they haven’t tuned in to the other episode? It was fabulous. If you haven’t tuned in, go back and look for it. Could tell our audience a little bit about what makes you, you?

I am probably deeply seated, both in science and in mystery. I value both approaches to health, life and problem-solving equally. I was having a conversation with a patient before this. She’s newly divorced. She’s diagnosed with rheumatoid arthritis. She is taking some hormones. She had a tough winter with multiple cases of pneumonia. I was talking to her about the complex web of her biochemistry, thinking about pulling on different strands of the web, how that changes her health, and having no idea what is going to happen when we drop a molecule into her bloodstream.

We spent a lot of time talking about that. We spent some time talking about peptides because I’m doing a certification course on peptides. Similarly, how much is known about the body and how much is truly not known. Particularly when we think about each of us as individuals and our biochemistry being unique to our genetics, our environment, our nutrition, and all of those things.

It can make it difficult to make clinical decisions about treatment. At my core, I have no idea what’s going to happen and people still want an action plan. It’s trying to marry what’s known, what’s not known, and all of the variables that exist that we’ll never be able to quantify and leave room for them in the equation of what anyone’s experience is of a treatment plan.

Thank you for that beautiful, honest preface, because I know I tend to do this, where my body is like an automobile. If I put this gas in it and my friend puts this gas in it, then we will have the same outcome. We’ll both be able to go 60 miles an hour and do this and that. As you pointed out, it’s a beautiful place to start because it does target the reader’s question, who’s saying, “It’s worked for my friend. My friend thinks that it helped her with X, Y, and Z.” I’m not saying that wouldn’t work for her, but it may work differently because she is different.

Her physiology is different, her genetics, the whole picture, what her daily lifestyle is like, and her food intake. That’s the part that is frustrating because I know I’ve been there. I want to be able to get this result. If I do what you tell me, I will get this result. That takes us back to your statement that you are in the science and the mystery. I’m not blaming our medical practitioners, but so many of them want to know it all or portray that they know it all. They are not willing or able to slow down and realize that a big part of it is a mystery.

For me, having tended births for a long time and being present when babies are born, there is nothing more humbling than watching that process and knowing that you can have the Buddha incarnate have a disastrous labor. You can have a young junk food-eating, cigarette-smoking teenager pop a baby out in a short period of time to realize there are factors at play here that we know nothing about. Clinical practice has taught me that.

Estrogen is a fabulous example for most women. Estrogen has a potent anti-inflammatory effect. I have prescribed it many times for that reason, for joint pain. Every now and again, I have a woman who’s like, “I’m worse.” I’m like, “That was not the intended goal of the therapeutic intervention.” I’ve seen it before where I make a recommendation. I think I’m being helpful, and I’m not. There’s nothing more humbling than realizing that you don’t always know.

That is the beauty of it and the humbling part of it. As practitioners, we lead with our knowledge, our experience, and with best practices. Sometimes, even that lovely blend of three doesn’t yield the anticipated or hoped-for result. I can’t continue without asking you another question. You talked about peptides. For those of us who aren’t up on our science, could you talk a little bit because then we’ll leave that behind and jump right into hormones but I don’t want to skip over that piece.

I’d be happy to define them and happy to come back and have another conversation. I feel like it’s a whole other conversation. I am in the infancy of learning. I feel like I’m learning a new language. It’s like I’m learning Italian for the first time, and I have no idea or very little idea of what I’m talking about. In short, peptides are a short chain of amino acids as opposed to proteins, which are longer chains of amino acids. We have endogenous peptides, meaning our body makes them naturally. Insulin is an example of an endogenous peptide. Growth hormone is another example.

Peptides have risen to fame of late because GLP-1 is a peptide. With the weight loss medications, GLP-1s are having their moment in the sun. Not unlike hormones that are having their moment in the sun for not dissimilar reasons. That, in short, is a peptide. They are controversial. They are complicated. Some of them are FDA-approved. Some of them are not. Some of them are pharmaceuticals, compounded, injectables, topical, and liposomal. They’re out there. They’ve been around for a long time.

They have a long history of being used in sports performance medicine, which I find fascinating. My interest in them grew from an interest in how to support people’s immune systems because I see people who can’t walk down the cleaning aisle in the grocery store because of the smells. Chemicals are too much for them and make them sick, or they can’t handle living in a city because of exhaust, or they can’t handle perfume. There’s a subpopulation of people whose immune systems have not adapted to our exposures of the 21st century. Peptides might be a useful tool to help them so that they can live and be well.

Why HRT Is More About Aging Better

Thank you for that very eloquent summary. When we look at hormone replacement therapy, my understanding is that we are replacing the levels of hormones that were in the body at a younger age or we wanted to have in the body at a younger age at an appropriate level for the body. Is that a good way of summarizing it or do you have something to add?

It’s interesting, because even some of the language around hormones has changed. It is largely now being referred to as menopause hormone therapy or menopause therapy. The idea of replacement is being a little bit circulated with the idea that there are some people, for sure, who are looking to replace what they had. There is a bigger group of professionals and people who are looking to support themselves aging well now. The goal isn’t necessarily to have hormone levels like they had when they were 30, but more to address whatever the current issues are now. The language now is menopause hormone therapy as opposed to hormone replacement therapy.

It is for our audience who is thinking, “Maybe, I’m pre-menopausal.”

That’s a beautiful little niggle that I can see women being like, “Does that include me? Am I included in that? What is menopause?” We have some rabbit holes we can go down. Let’s back up a little bit and define some terms. Perimenopause is the time that leads up to menopause, which is a day that is a one-year anniversary from our last period. Menopause is a moment in time. All of the hormone shifting that happens prior to that typically starting after the age of 35 is considered perimenopause.

That’s perimenopause. Hormones are given during that time. For many people, that happens to be the most tumultuous time because those hormones start changing. It can be hard to manage. That menopause is that one-year anniversary. Everything after that is considered post-menopause. I want to speak to something that you alluded to earlier, of our generation of women, maybe being too late or women who think they’re too late to the game or too late to access hormone therapy.

I’m reminded that guidelines are guidelines. That doesn’t mean that that’s a rule that has to be followed. For example, the current guideline around prescribing hormone therapy is that it is recommended to be initiated within ten years of the last period or prior to the age of 60. If a woman walks in at 63, and her last period was when she was 50, I’m having this conversation with her, and I’m saying, “Here’s the guideline.”

If she has bone health concerns, Alzheimer’s concerns, cardiovascular risk disease concerns, hot flashes, night sweats, vaginal dryness, muscle mass retention, depression, or joint pain. There’s a whole list of reasons why someone who’s 63 may want to consider initiating hormone therapy. For me, it’s not off the table just because she’s passed what the guideline recommends. Any woman out there who’s like, “I’m too old. I missed my moment.” I would suggest that maybe she hasn’t. She needs to find the right practitioner to sit down, have the conversation, and talk about the nuances of the recommendation and her unique circumstances.

Thank you. I’m fascinated by this topic. I’ve listened and read a lot on it. Can you talk for a moment, not that the reader brought this up, but for somebody who has had a cancer diagnosis. Before you answer, I want to remind our audience that we are not dispensing medical advice for any individual. Anything that we talk about, you want to take back to your care provider and discuss it with them. Know your medical history and order all the lab work to make sure that your individual needs are met.

We’re exploring the subject as a whole so that you can pull pieces, take them to your provider, and maybe get some insights and some excitement around the topic. Also, lose some of the shame and embarrassment that are so common with topics like this. We don’t want to be ashamed. We don’t want to be embarrassed. This is our body. This is our health. We want to be able to go in and have open and honest conversations and be met with the medical provider who’s going to look back at us with compassion and humanity and not condescension. If that’s your care provider, then switch providers.

How To Deal With Different Kinds Of Estrogen

Thank you for that qualification. For sure, this is not medical advice. This explores the topic of hormones. There’s a whole other conversation to have around hormones that I want to respond to what your question was. I have to see if I can remember it.

It was about cancer. It is for some of those who had the cancer diagnosis, not active.

I want to back up and talk a little bit bigger about hormone balance because this is a lot of the conversation that isn’t happening. Some of the naysayers around hormones are saying, “Menopause is not a disease of hormone deficiency.” That’s an important point to underscore that this hormone transition is 100% normal and natural. There is nothing wrong with what happens during this time of life. It doesn’t necessarily mean you have to accept it, particularly if you don’t want to accept it, given modern medicine and what it has to offer. I do feel like it’s important to reiterate that this is a normal part of life.

It’s a little bit complicated, where we didn’t use to live for 30 years without hormones. Our lifespan used to be much shorter. The chronic disease and illness that we’re seeing with a longer life can be tempered by having hormones on board. It’s a long time to live uncomfortably if one is uncomfortable. I’ll come back. To that to answer the question on cancer, the current risks associated with hormone therapy are thought to be largely related to estrogen. Let’s back up again to hormone therapy. When I say hormone therapy, what I’m thinking is a bioidentical estrogen. Which means it is biochemically the same as what the body makes.

There are no little extra molecules that the body doesn’t know what to do with. If a woman has a uterus, there is also progesterone. That progesterone is bioidentical. It’s the same as what the body makes. For women who are progesterone sensitive, when they’re given progestin, which is synthetic progesterone, like in birth control pills and in the progestin IUDs. F or some of us, that progestin blocks progesterone receptors and exacerbates low progesterone symptoms.

I learned that back in the day, when women were getting Depo-Provera injections, which were progestin injections for birth control. Some of those women would get diagnosed manic. When in fact, what happened was they responded to the synthetic progestin. It’s a big deal. I didn’t understand the nuances between progestin and progesterone but for some of us, it’s real. When I’m talking about hormone therapy, I’m talking mostly about bioidentical estrogen and progesterone. I’m talking about estrogen that’s delivered trans-dermally meaning through the skin.

Patches and gels are standard pharmaceutical preparations of estradiol that are bioidentical. Any medical practitioner should be versed in them. There is a standard pharmacy bioidentical progesterone in a capsule. The brand name is Prometrium. There’s some flexibility in the dosing of that. In both of these, there are bioidentical formulations that are standard pharmacy. I’m always amazed at the number of medical practitioners who have no idea. Women in our savviness will show up and be like, “I want bioidentical hormones.”

The conventional practitioners will say, “I know nothing about them.” My response is, “They don’t understand their formulary.” I will say that I am never an advocate of people taking oral estrogen. It is typically synthetic. It then has to be broken down first in the stomach and then in the liver. Many people have digestive issues, which is going to change the way they detoxify oral estrogen. There are many genes that regulate the way we break down estrogen in our bodies.

Those metabolites are being studied quite heavily as markers related to health protection or an increase in disease risk. You can measure those metabolites through urine. Those kinds of studies are happening at places like Johns Hopkins. This is the kind of testing that conventional practitioners don’t typically have access to, but that’s some of the information that I’m interested in. Hormone therapy, also in my mind, often will include DHEA, which is an adrenal-produced hormone. It happens to be the biochemical precursor to testosterone, which is also the biochemical precursor to estrogen. It’s important to understand the pathways of hormone production.

If I’m going to go there, then I’m going to be compelled to talk about cholesterol because cholesterol is the biochemical precursor to pregnenolone, which is the precursor to both progesterone and DHEA, the precursor to testosterone, the precursor to estradiol. If you have a woman on a statin whose cholesterol is being tanked by that medication, she is not going to have the biochemical precursor that she needs to be able to make her hormones.

I have a question. You’re talking about estrogen and estradiol. Please explain.

There’s more than one kind of estrogen, at least three. I heard there may be a fourth. All standard pharmaceutical medications are estradiol, which is our largest circulating estrogen and the one that most dramatically declines during menopause and is largely thought to be responsible for hot flashes, night sweats, and vaginal dryness.

Thank you for that clarification.

That’s a mincing of terms for me. Thank you for using estrogen and estradiol interchangeably. Thank you for that. Risks are largely associated with estrogen or estradiol. They are thought to be uterine cancer and an increased risk for blood clots and stroke. Up until 2025, one of the risks associated with estradiol was thought to be breast cancer.

With the re-examination of the Women’s Health Initiative, that risk was redacted, which is huge for many women. Women with strong family histories of breast cancer and women with personal histories of breast cancer. There’s a very incredible book called Estrogen Matters by a physician and oncologist, Avrum Bluming. I’m ashamed to say that I can’t remember his writing partner’s name.

He was a gynecologic oncologist whose wife was diagnosed with breast cancer and given estrogen. There’s this whole world of research around how estrogen can help people with breast cancer. In any event, the current status of the union with risk is thought to be related to uterine cancer and an increased risk of a blood clot.

Unpacking The Women’s Health Initiative

You refer to the Women’s Health Initiative, and I did earlier. Could you take a moment to explain that? If people want to look, there’s a lot of press on it. I hope it still stays current because it’s big. It is big for blasting through some of the myths, misconceptions, and bad science.

A brief word on the Women’s Health Initiative was a study that was done that took women and put them on one-size-fits-all synthetic oral hormone therapy. It turned out that it didn’t go very well.

There were women in their 60s and 70s. It was not an appropriate population to study.

There were tons of limitations around the population using one specific intervention. The way that the data was reported was very misrepresentative of the findings. That got completely unpacked in 2025 and publicized, which was the fodder for the change in the recommendations without getting too mired in detail.

Also, if my understanding is correct, they weren’t bioidentical hormones. They were equine. That’s so important. What hurts is that medical practitioners, including mine, were telling me when I was asking questions that, “Based on the current research that we have, we do not do this unless X, Y, and Z.” I wasn’t having hot flashes. I wasn’t having the big symptoms. To be aware that even though this is now year-old research, some medical practitioners and some healthcare systems still have not jumped on the wisdom boat.

It is mind-blowing to me the number of women who I see who were put on oral conjugated estrogen products like Premarin, where the data is so clear that the risk profile with that estrogen is high. I know that there’s been some mincing around bioidentical and people poo-pooing bioidentical and any estrogen is going to be bioidentical. I feel like, Carla, this is a case where it’s hard to know. You can find research that supports any position you want to take. Maybe I’m an old dog who needs to learn new tricks. It’s a little bit astounding to me that I’ve been prescribing hormone therapy for over twenty years.

I am so grateful for the way that I was trained, which was bioidentical only through the skin with the estrogen. You often want to give progesterone orally because it has anxiolytic or anti-anxiety properties and can help women a lot with sleep, which is one of the giant issues that comes up for people. That’s how I was taught to prescribe. One woman at a time. Not this universal dose of 0.0625 milligrams of conjugated equine estrogen with however much progestin to all women across the board, regardless of their height, weight, lifestyle, nutrition, and stress levels. It didn’t go well.

To me, it speaks to the importance of looking at a woman within the system, the context of her life, and all of those other variables. Is she moving? Is she training? Is she strength training? Is she doing interval training? Is she eating high protein? What is her stress like? The point that I wanted to come back to is the whole concept of the HPATG axis. That stands for the hypothalamus-pituitary-thyroid-adrenal-gonadal axis.

Gonads in women are the ovaries. Adrenals are small glands that sit on top of our kidneys, which are primarily responsible for cortisol, our stress hormone, and DHEA, which we’ve already talked about as the precursor to testosterone, which is the precursor to estrogen. A lot of women know that if they’re stressed, their hormones go wacky. We think about when we were teenagers. We had a big exam or a big performance, and we skipped a period or two or three. We knew that when we were stressed, our hormones changed.

That is the most profound, perfect storm that happens for midlife women that profoundly affects their hormone balance. There are people within the field of functional medicine when talking about hormone balance, say, “Adrenals, adrenals, and adrenals.” When you look at the hierarchy of the organs, the adrenals are at the top. You can’t expect or achieve hormone balance if stress is not being mitigated by lifestyle. Our culture does not want to hear that. As women, we don’t know how to do it.

We’re like, “How are we supposed to do that? There are only so many hours in a day. There’s work. There’s home. There’s caregiving, children, parents, family, pets, and all the things. Within the context of a day, how am I supposed to have a quieting practice that quiets my central nervous system so that my adrenals can function optimally so that I can make DHEA and cortisol so I can fill the well from which testosterone and estrogen are derived?”

Simple Practices To Maintain Hormone Balance

Thank you for that beautiful rundown. It’s perfect because we keep circling back to the reader’s question. Some of her mood disturbances are maybe hormone-related. For her to have to choose between psychotherapy and medical care is a statement about our world. It is realizing that for all of us, it is paying attention to when we’re stressed and using something as free and available as our breath to stop and do.

I know if I find myself starting to rev up, even a simple thing like waiting for my computer monitor to turn on after it’s gone to sleep. Instead of being irritated while I wait for it to go back on, I use that for deep breath in, deep breath out, and cleansing breath. We realize all of these little moments throughout the day, like waiting in line at the supermarket and waiting in line at a traffic signal, are our opportunity. Our eyes can certainly be wide open, especially if we’re in traffic, but we can do some breathing.

I don’t want to underestimate it because I know its value in my own life and in my client’s life. If we can remember these simple practices, and I have to emphasize it. Thank you, Carrie, for bringing it up, because you’re right. Those are the adrenals sitting right there atop the kidneys. They play such a critical role in our overall wellbeing. When we’re younger in our teens and twenties, we don’t notice any. We’re just powering through

Every time another calendar year goes by, our bodies become less resilient. That’s the idea. Sometimes, doing cleansing breaths, journaling, meditation, or a walk are mood boosters that can work synergistically. They’re not a replacement. It’s not an either/or. It’s about creating. I hear you talking about creating this beautiful synergy of mental health, physical health, and keeping that circle going. Am I on the right track with what you are conveying to us?

Yes, 100%. To reinforce it a little bit more is to understand that the normal, natural order of things is that as we age, we don’t ovulate regularly anymore. When we don’t ovulate regularly, we don’t make progesterone consistently. We end up in a low progesterone state. When that happens, the burden on that HPATG access is higher. There’s more pressure on the thyroid. There’s more pressure on the adrenals to do the job, which is why, in my opinion, there’s so much midlife hypothyroidism, at least part of the reason. There are some other reasons, too.

It’s understanding that our hormones exist within a system and that part of balancing them isn’t just adding them. Part of balancing them involves addressing the entire system. That’s how, in my opinion, you get optimal wellness because you can take hormone therapy. Let’s say you’re taking it because you want the potential body composition benefits of taking hormones. How many women do I know taking hormones who thought that was going to be the magic bullet? They’re not doing what they need to be doing nutritionally or movement-wise to get, as you said with the most beautiful word, the synergistic result.

It isn’t either/or. It’s both and. Part of hormone balance involves addressing stress in our lives. That means marriages. That means relationships, jobs, and doing the boundary work that we’ve blown off up until our biochemistry said, “Not anymore. You will not blow me off anymore.” It’s a reckoning. It’s a real powerful reckoning. It can be humbling.

One of the big reasons I love having conversations like this and spreading this wisdom is that we have become in our very consumer-oriented society used to, “If I go and take this pill or do this one thing, then my life will be better. I will feel better.” Our bodies are such complicated systems. Mental health and physical health are so complex and unique to this imperfect individual. What I found and in working with other clients, we’ve come to the same conclusion that it is about personalizing the journey and willing. Whether we’re working with physical health or mental health.

Other people may be doing something that’s working for them, but you need to be doing what works right for you. That involves a commitment to tweaking, learning, growing, and going into the mystery of your system. It’s not just the physical body. It’s the body-mind-spirit, that holistic connection, loving yourself, and respecting yourself enough. For some people, it can be easier. It sounds like her friend. There was like a magic bullet. Whatever happened. I don’t know. For many people, it is a journey of dialing it in.

I certainly have taken care of plenty of women who initiated hormone therapy. They show up, and are like, “That was completely game-changing. I am a completely different human being.” That happens for real, at least in my practice. Does that happen all the time for every woman? Absolutely not. Do some women come back and say, “This is better and this is better, but this hasn’t changed at all?” One hundred percent.

I thought of this earlier. I wanted to mention it. There is no aspect of healthcare in my practice that is more the art of medicine than hormone balancing. It is a little bit of this, a little bit of that, and some time. How do you feel? What’s the same? What’s better? What’s worse? Let’s change this. Let’s do that. Let’s try toggling this thing over here. Where are you? Are you where you want to be?

This idea of one-size-fits-all hormone therapy is madness. I don’t see how that could work for the masses to the extent that I’ve sat at tables with practitioners who are pulsing the hormones, which means changing the level like day to day. This physician was like, “There’s way too much breakthrough bleeding. I’m seeing way too much breakthrough bleeding. I see much less breakthrough bleeding when pulsing.”

I’m thinking to myself, “I get that. That probably more closely mimics what happens in the body.” Our hormone levels are not a steady state that depends on all the things we’ve talked about, stress, how many hours of daylight, how much vitamin D, what we ate, did we poop, and all these things. I was like, “How into the weeds do we go and do we have to go, for people to feel well?” It’s interesting.

Addressing Your Unique Needs With Personalized Care

When you talk to us about that bigger picture, again, it takes us back to personalized care. The key is personalized care because I have talked to women. My clients tell me everything. I’ve heard everything from joint pain evaporating to sleeplessness issues changing or not changing, the breakthrough bleeding, and stomach issues, but it can be worth it.

Back to the reader’s question, we can’t recommend one over the other. I wish you didn’t have to make that choice of putting your money in one or the other. It is being able to look at your situation. Maybe it’s getting support psychotherapeutically through a free women’s group or starting a group and then channeling money into investigating or finding a healthcare professional, such as you, who believes in the personal care.

I was thinking about your reader’s question as well. I was like, “I don’t think that there’s a right answer to that question.” If she were sitting in the office with me, I would be asking her. Does she have a history of trauma? What is stress in her life like now? How are her primary relationships? How much of her life is consumed with challenging emotional issues? Is she not sleeping? Is she having hot flashes? Is she having night sweats? Is she riddled with pain so that she can’t think, she can’t move, she can’t sleep, and is trying to help her triage? I don’t think it’s an either/or. It’s a question of, which first?

It’s also so important for her to understand that there are bioidentical hormones that are available through a conventional practitioner. If she has health insurance, are insurance reimbursable? The hitch is finding a practitioner who is versed and comfortable enough in the nuances and isn’t going to give her what she thinks is the right prescription and say, “See you. Good luck. I hope it goes well.” Instead of, “I want to see you in twelve weeks, check in, and see how you’re doing. I want to hear from you in three weeks before your next refill to decide whether or not we should adjust your dose.”

Creating Refinement Instead Of Starting Chaos

There are the appropriate labs and blood work, and the availability if it starts with the HRT and has issues. Even if the doc’s busy, is there a nurse available? Do you get true guidance, or are you put into a box, and as you said, go deal with it? I know we’re running low on time, so I’m going to see if I can squeeze in two questions. The patches and creams versus pellets. I know you’re not doing pellets, so that does tell me something. What are your thoughts about the HRT pellets where they implant them in the skin? I think it’s quarterly sometimes, depending on the individual.

I have zero experience with pellets. I have many women who come to me having experienced pellets. For me, the idea of having an incision and something implanted personally would stop me right there. Maybe that’s why I never became amenable to it. That’s a super high level of intervention for something that ideally is supportive. There’s that. The pellets too don’t allow for the nuance, the dialing in, or the fine-tuning.

If someone’s working and they dial into one dose and that dose is pretty constant for them, maybe that’s great. If she doesn’t feel like having an incision and walking around with an implant as uncomfortable for her, maybe that makes sense. In my experience, hormones are so dynamic relative to the stress in a woman’s life that it’s not so much what I want. Women benefit from having the flexibility.

How much toggling do you do that’s refinement versus creating chaos? That’s a little bit of a slippery slope and something nuanced. That’s where experience comes into play. I’ll take care of women who adjust to their own stuff all the time. They’re snipping their patches. They’re putting two on. They’re doing whatever women do. I’m all for women taking their health into their own hands, except for when they’re creating confusion as opposed to creating clarity of what’s the same, what’s better, what’s worse, and what needs to be adjusted to address the concern.

How HRT Helps Address The Epidemic Of Prediabetes

I could see somebody saying, “I have these patches. I’m more stressed. I’m going to add and stick on another patch.” Don’t address the stress, but stick on another patch. Next question. Since we’re in this epidemic of pre-diabetes, have you seen an association between A1C levels lowering with HRT, or have you not seen? In your practice, what have you seen?

It would be difficult for me to make that correlation because I am always counseling women about the complementary nutrition and movement recommendations that accompany midlife. Decreasing our carbohydrates, increasing our protein, and adding resistance training and interval training are going to have a profound impact on our hemoglobin A1Cs and our fasting insulin. It’s interesting.

Stacy Sims is a Stanford-trained exercise physiologist who focuses on women. A lot of my exercise recommendations come from her. She has two incredible books for your audience. One is Roar for women who are still of childbearing years, and then Next Level for women who are peri and post-menopausal. In her books, she’s not a super big fan of hormone therapy. When I first read her books, I was like, “I don’t know if I align with that.”

I heard her speak. She gave a long presentation about what resistance training does to the muscle fiber is the same as what estrogen used to do to the muscle fiber. What I realized was that she is saying to women, “Do the work first.” You have to do the work. You have to eat the protein. You have to lift the weights. You have to do the intervals because just doing the hormones isn’t going to always get it done.

Thank you so much. That’s such an important piece because often, as we get older, we tend to do less exercise. We tend to do more sedentary things, or we tend to get into one way of exercise and forget about the other types. We forget the weights. We forget the resistance. Not that all pre-diabetes is associated with this, but I love how you’re looking at it as, “Your body simply needs you to do more of this.” More proteins, fewer carbs. Maybe you were able to do that in your 30s and 40s. Not anymore. It’s more protein, less carbs, more strength training, and more resistance training.

Part of why that happens is because when we lose estrogen, we become more insulin-resistant. That midsection weight gain is insulin resistance. That can be related to cortisol and estrogen. She’s saying there’s stuff we can do even before we touch hormones.

I want to emphasize you’ve full circled back to stress. When we are stressed, we have elevated cortisol, increased belly fat, all of those things, and so much more. Looking again holistically, there’s a lot, regardless of our sex, that we can be doing than reaching for.

You’ll see it in men, too. We see the same thing, the midlife midsection weight gain, the gynecomastia, the breast development in men as they age. That midsection weight gain is also insulin resistance, either because of stress or because of changing levels of testosterone. Remember when the stress is high, and the body is like, “DHEA,” to manage the stress, you don’t even have the biochemical precursor that you need for testosterone, which is waning anyway. That midlife calling is not sex specific. That is universal.

How Women Should Take Testosterone

I’m glad we started the interview by talking about that piece of weight, regardless of what your sex is and regardless of how you identify with your gender. This is an issue for all of us to be looking at as early as our late twenties or even before then to have conversations, to be looking at it. It’s so much easier for us to think that we can just go and pop a pill or do an injection of a semi-glutide and it will magically fix everything. There isn’t magic out there. We have to be doing our part. We have to be moving more. We have to have a variety of exercises. The last piece is that a lot of women are being advised to take testosterone. Do you have any thoughts on that?

Testosterone is the latest star in the hormone therapy story. Testosterone is having its moment now. It goes back to that personal experience. What are the personal concerns? What are the personal goals? What’s an individual’s experience? I have been prescribing testosterone for over twenty years to women. Historically, it was for libido and then sexual responsiveness. Women will say things like, “I feel dead down there or there’s a real difficulty with orgasm, responsiveness, and shrinking.” Anatomically, the clitoris gets smaller. That’s a thing. That’s real. It happens. That’s going to change sensation, orgasm, and responsiveness.

Testosterone can help with all of that, along with libido, but that’s not the whole libido story either. Libido is so complicated. It is not just a testosterone story. There’s the body composition piece. More and more women are talking about the mental acuity that they notice when they take testosterone. It’s out there. It’s another tool in the toolbox. Sometimes, when I’m doing hormones with people, and everything is low across the board, we start with DHEA because then you’re giving the upstream hormone. You’re giving the biochemical precursor to testosterone. It’s not always about giving the thing directly.

Sometimes, it’s about filling the pool and then seeing what happens to that hormone in someone’s body. This is where I don’t know what’s going to happen. I can give someone DHEA, and her body may suck it up as DHEA. She might be like, “I can now stay awake until 9:00 PM. I’m not falling asleep on the couch at 7:00 PM every night, but my libido is still terrible.” Some women take that DHEA, and they’re like, “My libido is amazing. The hot flashes are gone because it goes down that pathway, but I don’t know what it’s going to do.”

Discussion Wrap-up And Closing Words

Thank you for taking us back to the mental health piece when you were talking about how libido is not just about hormones. It is also about how you feel about your body, yourself, your partner, and your relationship. There’s so much. We could go to another rabbit hole. Carrie, you are a font of wonderful information, wisdom, kindness, and authenticity. I so appreciate you and the beautiful guidance that you offered us. Again, our audience, take it to your medical practitioner, but also do some investigation so that you go in as armed as possible with research that the medical practitioner may or may not want to listen to.

One last word of unsolicited advice to your audience. Don’t get your hormones online. Please don’t do that because I’m seeing inappropriate prescriptions, like women on birth control pills also being put on estrogen.

It gives me shivers and also some anger when I think about the types of what we could call malpractice happening because you need to be qualified to be doing what you’re doing. As you’ve said, it is art and science. It is a mystery. It is about that unique individual who is trusting their care to you. They’re entrusting you with their wellness.

Sometimes, online factories don’t give the attentive care that’s needed. Carrie, thank you again for your wisdom. I am so appreciative. To our audience, thank you as always for being on this journey of love and life, being imperfect and human just like me. It’s such a beautiful journey to be on together. This is Imperfect Love.

Important Links

• Carrie Levine
• Carrie Levine on Facebook
• Carrie Levine on Instagram
• Carrie Levine on LinkedIn
• Whole Woman Health
• Whole Woman Health: A Guide to Creating Wellness for Any Age and Stage
• The HUGE Health Benefits of Reducing Stress and Eating Well – Previous Episode
• Estrogen Matters: Why Taking Hormones in Menopause Can Improve Women’s Well-Being and Lengthen Their Lives — Without Raising the Risk of Breast Cancer
• Stacy Sims
• ROAR: How to Match Your Food and Fitness to Your Unique Female Physiology for Optimum Performance, Great Health, and a Strong, Lean Body for Life
• Next Level: Your Guide to Kicking Ass, Feeling Great, and Crushing Goals Through Menopause and Beyond
• HHS Advances Women’s Health, Removes Misleading FDA Warnings on Hormone Replacement Therapy
• NAMI HelpLine
• Mental Health and Relationships – MyHealthfinder
• Dr. Carla Manly’s Website
• Dr. Carla Manly on Instagram
• Dr. Carla Manly on X
• Dr. Carla Manly on Facebook
• Dr. Carla Manly on LinkedIn
• Dr. Carla Manly on YouTube
• Dr. Carla Manly on TikTok

About Carrie Levine

Carrie E. Levine, CNM, IFMCP is the founder of Whole Woman Health, and author of Whole Woman Health: A Guide to Creating Wellness for Any Age and Stage.

As a certified nurse midwife and an Institute for Functional Medicine Certified Practitioner, Carrie evaluates and treats most common women’s health concerns, incorporating gynecology and functional medicine.

Previously, Carrie practiced gynecology and functional medicine at the world-renowned Women to Women health care clinic in Maine from 2006 to 2014. Prior to that, she practiced full-scope midwifery at Miles Memorial Hospital, now LincolnHealth, in the beautiful mid-coast Maine town of Damariscotta.

Carrie is known for her ability to listen to and relate to women. For more than twenty years, she has been working with her clients to identify personal health goals and then to break those goals down into attainable steps. She looks for the underlying causes of illness, seeking to connect the dots of seemingly unrelated symptoms and emotions. By supporting women in setting and achieving their own health goals, Carrie helps her patients thrive emotionally, spiritually, and physically.

Carrie earned a Bachelor of Science degree in Public Relations and Women’s Studies from Syracuse University. She went on to earn her RN and MSN from Case Western Reserve University. Her certificate in Nurse-Midwifery is from the Frontier School of Midwifery and Family Nursing.

She is a member of the Maine chapter of the American College of Nurse Midwives, the Maine Nurse Practitioners Association, and the Institute for Functional Medicine.