In Episode #48, Dr. Jill interviews Dr. Pam Smith on bio-identical hormone therapy and the importance of HRT compounding pharmacies.

Dr. Pam Smith: https://www.centerforpersonalizedmedicine.com/find-a-physician/pamela-wartian-smith-m-d

More Reading: Andropause: The Male Menopause

Dr. Jill

Dr. Jill Carnahan is Your Functional Medicine Expert® dually board certified in Family Medicine for ten years and in Integrative Holistic Medicine since 2015. She is the Medical Director of Flatiron Functional Medicine, a widely sought-after practice with a broad range of clinical services including functional medical protocols, nutritional consultations, chiropractic therapy, naturopathic medicine, acupuncture, and massage therapy. As a survivor of breast cancer, Crohn’s disease, and toxic mold illness she brings a unique perspective to treating patients in the midst of complex and chronic illness. Her clinic specializes in searching for the underlying triggers that contribute to illness through cutting-edge lab testing and tailoring the intervention to specific needs. 

Featured in Shape Magazine, Parade, Forbes, MindBodyGreen, First for Women, Townsend Newsletter, and The Huffington Post as well as seen on NBC News and Health segments with Joan Lunden, Dr. Jill is a media must-have. Her YouTube channel and podcast features live interviews with the healthcare world’s most respected names. 

A popular inspirational speaker and prolific writer, she shares her knowledge of hope, health, and healing live on stage and through newsletters, articles, books, and social media posts! People relate to Dr. Jill’s science-backed opinions delivered with authenticity, love and humor. She is known for inspiring her audience to thrive even in the midst of difficulties.

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#48: Dr. Jill interviews Dr. Pam Smith about Bio-Identical Hormone Therapy

Dr. Jill  00:12
Hello everybody. Thanks again for joining us today on this Friday afternoon—depending on where you're at—the time here in Colorado. It's 61 degrees in January. It's absolutely gorgeous. It's one of those days where I was just on the slopes of Breckenridge this morning skiing—a beautiful day—and then came back here. And you could probably golf. I don't golf, but it's that kind of a beautiful Colorado day. 

Dr. Jill  00:34

Today I have an esteemed guest whom I have such great and deep respect for. As I was telling her before we got on the call, it's just an honor to have her time. She serves in so many capacities and ways, and has always been a brilliant writer and mentor—and in so many ways in my life. So I really appreciate that. Let me introduce her. 

Dr. Jill  00:59

Dr. Pam Smith spent her first 20 years of practice as an emergency room physician at the Detroit Medical Center. And then she's been—I don't know how many years, this might be old—26 years as an anti-aging functional medicine [doctor]. Has it been longer, Dr. Smith?

Dr. Pam Smith  01:15
Yes.

Dr. Jill  01:14

Yes. Anyway, a long time. She is a great teacher. I think we first met through A4M, but we've crossed paths on so many levels. And like I said, she is a producer of great content and great lectures. What I love about Dr. Smith's way of writing and teaching is that it's just so succinct, [with] lists and formulas. It's super easy to consume for those of us who are learning. She's just been a great mentor. I bet almost every physician who's in functional, integrative, holistic, personalized, or precision medicine has some story of Dr. Smith being a part of their training on some level. I could say so much more, but I just have the greatest respect that you are here today with me, Dr. Smith. And I thank you for your time. 

Dr. Pam Smith  02:03

Oh, thank you for the invitation, truly.

Dr. Jill  02:06

Yes. Today we're going to talk about hormones. So if you're listening as a patient, client, or someone who has seen a doctor about your hormones, we're going to start with a little bit of the basics. And I'm going to ask Dr. Smith to kind of lay the groundwork here. But what's really important today is that we are at risk as physicians—and, if you're listening, as patients—of losing our ability to get bioidentical compounded hormones.

Dr. Jill  02:33

I always say our toolbox as conventional allopathic MDs is quite small. And it's very powerful. We use medications and surgeries, and any of us in the field find those tools incredibly helpful. I know, like Dr. Smith, that I value my training in conventional medicine because it's given me this rich foundation of diagnosis and treatment. However, now that we're doing precision and personalized medicine, there's this greater toolbox. And one of the tools that I think is probably the most powerful thing we have outside of just conventional pharmaceuticals is competent hormones.

Dr. Jill  03:07

So, Dr. Smith, I'm going to let you talk just a little bit about: Why is this important for women and men and [people of] all ages? Let's just set the groundwork first.

Dr. Pam Smith  03:17
Thank you so much, truly. Hormonal therapy is really interesting. People ask: Why do you need to be on hormones? Do you need to be on hormones?—etc. So just follow the science. What does the science really show? Let's start with women. Estrogen has 400 functions in the body—400! So it's taste, touch, smell, hearing, and skin tone. It lowers cholesterol, blood sugar, and blood pressure. And there are many studies to show that for women, it is your memory, literally. So that is the reason why it's so important to look at estrogen. But there are three estrogens, and a lot of doctors even don't know this. There's E1 (estrone), E2 (estradiol), and E3 (estriol). 

Dr. Pam Smith  04:11

When you need hormone replacement of estrogen, we do not replace E1. It is the one that is linked to breast cancer. E2 is the [one with] 400 functions. E3 is the one that helps prevent breast cancer. A lot of people ask us: Is this new information on E3? It's not. The first article came out in JAMA 96 years ago, so it's been a long time since we have known about E3. And it does matter if it balances with the other hormones. Estrogen has to balance with progesterone. And not every woman needs estrogen in her life. Some women never lose estrogen. Estrogen is stored in fat cells. So if you're a little bit overweight, then you may not lose estrogen right at menopause. Some women never lose it. We only replace the hormones that you lose. 

Dr. Pam Smith  05:08

Progesterone is its balance. The symptoms of progesterone loss are anxiety, irritability, insomnia, mood swings, depression, heart racing, bladder problems, gut disturbances, etc. Women can lose progesterone or have an imbalance of progesterone to estrogen at any age. PMS, PCOS, perimenopause, menopause, and PMDD tend to all be low progesterone states. So it's important to have progesterone for balance. It's just huge. 

Dr. Pam Smith  05:43

When it comes to testosterone, that's a different story. Testosterone—not all women lose testosterone. I will be 67 in July. I still have very normal testosterone. It's the dead center of normal, which means I probably will not lose testosterone in my lifetime. Of that remaining, one-half of people—one-half of them—end up with high testosterone, [and] one-half end up with low. And that can occur at any age. PCOS, or polycystic ovarian syndrome, is high testosterone. We don't want to leave it there, because high testosterone drives up the risk of heart disease, and it drives up the risk of blood sugar being elevated. We don't want to leave testosterone too low, because it's very important for our sense of well-being, sexual interest, and bone strength.

Dr. Pam Smith  06:38

So all those hormones are made in the ovaries, and they do decline with age. But it's important to replace them at the right time. There are now several studies showing that, when it comes to heart health and brain protection, we try to replace estrogen as soon as a woman loses it. Would we still replace it 20 years later if she's a candidate for it? We would, but there is more brain and heart protection if you replace it as soon as it's gone. It is a hormonal symphony. That is the way God made us. It is supposed to be balanced. So DHEA and cortisol made from the adrenal glands are part of that balance. And DHEA makes estrogen and testosterone and balances cortisol, our stress hormone. And who isn't stressed in today's world? They're all made from a hormone called pregnenolone.

Dr. Pam Smith  07:37

If you've not heard of this hormone, I am going to spell it, because even some doctors have not heard of it. And of course, it's hard to say and hard to spell because it's a hormone of memory. It's P-R-E-G-N-E-N-O-L-O-N-E; pregnenolone. It makes estrogen, progesterone, testosterone, DHEA, and cortisol in both men and women. It is the hormone of memory and has many other functions in the body. It's made from cholesterol. And sometimes cardiologists don't realize that the total cholesterol has to be at least 140 to make pregnanolone. If they get the total cholesterol too low, then the body doesn't make pregnanolone or the remainder of those hormones. So again, it's about balance. 

Dr. Pam Smith  08:29

And the same thing when it comes to men. Do they need hormone replacement? Many men do, yes. They lose hormones as well with age. So what does testosterone do for men? Of course, we talk about sexual interest, but it lowers cholesterol, blood sugar, and blood pressure. It is muscle mass, and it is their memory and energy. So it's so important. They make DHEA, they make pregnenolone, they make progesterone, and believe it or not, they make estrogen. Men need estrogen. They need it for memory and bone structure. Too much estrogen increases their risk of heart disease and prostate cancer. So are hormones important? They are. They're extremely important to maintain vision, memory, mobility, energy, and all the things that I just mentioned.

Dr. Jill  09:28
Now you all know why I love Dr. Smith because, as you just heard, she just gave us this overview that covered almost every little bit as far as why we need hormones as men and women and what happens as we age. And what we see in clinical practice is… I like to frame it in the sense of maybe 100 years ago, without the toxic load in our environment, without the infectious burden, without the stress levels, without the EMFs. There are so many factors now that are affecting our hormonal cascade that probably—I would love to hear if you agree, Dr. Smith—more than ever, we are getting hit with things that deplete our hormones or that affect our hormones. And there are things in our environment that have a chemical effect and have either estrogen-like effects or other hermetic effects on our body. So what we're seeing in clinical practice is a lot more disruption in these cascades—and I would say in younger and younger women as well. Would you agree, Dr. Smith?

Dr. Pam Smith  10:25
I do. In younger women and younger men as well. In both. When I first started practicing, I never saw a man under 47 years of age with low testosterone. Now we do. 

Dr. Jill  10:37

Right. Frequently. Right?

Dr. Pam Smith  10:40

Well, and with women, polycystic ovarian disease, when I went to school, was called Stein-Leventhal syndrome. 

Dr. Jill  10:48

Yes, I remember. Way back.

Dr. Pam Smith  10:52

And I was told I would see one or two cases in my entire career. Now I see 10 cases a week. So have hormonal balances changed in the last 40 years? They have dramatically [changed], and pretty much not for the better. But the good news is that science is here to help us go back and balance it and customize it for each and every person. 

Dr. Jill  11:15
Yes. And that's again, the importance of our talk today is that there are available options. What Dr. Smith and I can do—there are a myriad of compounding pharmacists who can create the exact mixes and doses based on good research. And that's the thing I want to talk just a little bit about as well: There is lots of strong evidence to support these hormones. Would you want to address that just a little bit?—because some doctors and patients have been told that there's either no evidence or there's no science to support what we're doing with compounding hormones.

Dr. Pam Smith  11:50
Well, number one, there are a myriad of articles supporting the use of hormones to begin with in both men and women. But let's take women, because that seems to be what is most controversial at this time. Are there articles saying that estrogen equals memory? [There are] hundreds of them in traditional medical journals. Are there articles saying that it is important to have natural hormones? It is. And what does natural mean? People usually think it means it comes from a plant. And hormones honestly do come from soy or yams, but that's not the definition of natural. In medicine, natural means the same chemical structure God gave you. That's the actual definition.

Dr. Pam Smith  12:36

When you use synthetic hormones, which are not the same chemical structure, you get disrupted messages, you get incomplete messages, and you don't have a balance between hormones. It's not guesswork. There are actual clinical trials [showing] that if you use synthetic hormones, there is an increased risk of other diseases, for example, breast cancer. That's not questionable anymore. Are these small trials? No. Some of the trials are [with] 80,000 women. [They are] large clinical trials showing that hormones are necessary, they're important to balance—you have to measure—and that they should be compounded. And use natural hormones for the patient, meaning the same chemical structure.

Dr. Jill  13:28
So let me summarize what I hear you saying, and then I'd love to hear if there's anything different from what I'm saying that is more accurate. It sounds like, from the research, this is what both of us do: As soon as a woman starts to lose her natural hormone, we measure this. You and I are scientists first. And as you would, I always would start with a measurement. There are multiple different ways in multiple different studies that show blood levels, urine levels, and saliva levels can all be accurate. 

Dr. Jill  13:55

I would love your comments on that in just a minute. But either way, we're measuring hormone levels. And then, as soon as that woman, whether she's 40, has early menopause, or is 50 or 60, is starting to really decline and have symptoms, what I hear you saying and what I would do in practice is start to replace those at physiological levels so that she has that function back in a safe way. Then I will typically monitor them, watch, and make sure that we're doing safe and balanced levels. And like you said, if you would just give estradiol, which is E2, without the progesterone to balance that, some of these things cause rapid cell division, and some of them cause the stopping of that division and differentiation. Those are these checks and balances that our body naturally has, so we want to replace them in conjunction as well. So basically, [it's about] testing and treating when a woman is symptomatic. 

Dr. Jill  14:46

Then, as far as how long we treat, I always talk to the patient with informed consent, and we decide together what they'd like to do and what the risks are. But I'd also love to hear your thoughts on when you might discontinue and how long you would keep them on. I know there's Dale Bredesen teaching on Alzheimer's. He's giving hormones for memory to women over 80 because, for them, memory is more important. And I do believe that that is appropriate in certain cases. What's your thought on that process? Is there anything you would do differently as far as assessment and treatment? And then, how long?

Dr. Pam Smith  15:20
Well, for one thing, honestly, I never stop hormones unless the patient wants to stop. My oldest patient currently on hormones is 102, and she's sharp as a tack. She still drives her own car, and she still flies around the world. She's just an absolutely fabulous person. So that's for both men and women. It really is about balance. But you have to measure. It's important to look at physiological—as you just stated—levels. We don't just give a lot of hormones, so it's “feel good.” Or is it just about symptoms? It's not.

Dr. Pam Smith  15:57

Of course, symptoms are really important, but these are hormones of repair. They build bone structure. They help prevent disease. But that's at physiological levels, usually in very small doses. For example, when a woman is 25, she makes her peak hormonal level. And for estradiol, the E2, pre-luteal, she makes about 365 micrograms. Micrograms—a baby's amount. And when people give her a massive amount of hormone just so that she feels good and the hot flashes are gone—that's not the idea. Fifty percent of hot flashes come from stress. We want to look at the cause of the problem. We replace it physiologically and in balance. 

Dr. Pam Smith  16:46

So I give hormones forever. At almost 67, I don't plan on ever stopping my own hormones. I did this year for one month over the holidays because, for the first time, I was not on call during Christmas—ever. So my partner took calls for me. And I always offered to take it as a senior partner. This year, I did not. So I stopped my hormones for a month just to see what would happen. Because, as a scientist, of course, the first person you look at is yourself and what happens. It was amazing. The first week, [there were] no problems. The second week, it was like, “I think I'm just a little bit tired, but, eh, it's the holidays.” The third week, “Oh gosh, my clothes feel a little tight.” By the fourth week, I had no brain. It's a good thing my partner was on call for me. 

Dr. Pam Smith  17:39

So I started back up my hormones. I've been on progesterone for 29 years, so it has been a long time since I stopped everything. And now I'm even more of a proponent for hormones. But again, in small doses. You have to measure. When we see patients in our practice, and I'm sure you do the same thing, we see them, we test them, we start hormones, we recheck them in 90 days, and then every six months thereafter. That way, we know they get the perfect dose for them.

Dr. Jill  18:15
And are you typically testing blood, urine, saliva, or a combination?

Dr. Pam Smith  18:22
I know there's a lot of controversy on this. So we actually just finished a clinically controlled trial in our practice. And we're going to publish this because there's been a lot of controversy. So there shouldn't be anymore. Dr. David Zava had studied this for many years, and we wanted to reproduce the studies and see: Were they indeed accurate? So I can absolutely tell you today that if you put the hormone on the skin, it will not show up in the blood. It absolutely, positively does not. We prove that.

Dr. Pam Smith  18:56

And estrogen for women and testosterone for women should always be transdermal, meaning on the skin. So if it's on the skin, blood is out for measurement. Also, when it comes to cortisol, the stress hormone, there are six clinical trials showing that the gold standard to measure cortisol—not for Addison's or Cushing's disease but for hormonal balance—is salivary testing. Even Quest and Labcorp offer salivary testing for cortisol. So when you measure cortisol, that does have to be by salivary. Transdermal, that has to be by salivary. If you measure something that you're taking orally, perhaps progesterone, for example, or DHEA or pregnenolone, you could use serum. But it's more expensive. It's much more cost-effective to do all of it by saliva.

Dr. Pam Smith  18:49

Urine is a very important test, but it's a metabolite. It's a breakdown product. Honestly, you can't dose off of a breakdown product. Do I do urine tests to look at breakdown? Yes. I want to make sure that her estrogen is breaking down into the right estrogens, so she has a decrease in breast cancer, etc. And all the other hormones too. But I don't recommend dosing off of urine because then you're dosing off of a metabolite and not the hormone itself like you would be with saliva testing.

Dr. Jill  20:23
Oh, see, this is so tremendous because, like you said, there's a lot of controversy and you hear everything out there. And one thing I want to talk about for those of you listening is that Dr. Smith mentioned oral dosing. If we give oral hormones, they have to go through the liver, phase one and phase two. It's kind of a dirty way to do it, and it actually stresses the liver. The liver is already doing the detox work of chemicals and everything else, so the less we can put through that pathway… If we do it transdermally, we're doing it much more like how the ovaries actually release it into the tissues, so I couldn't agree more. Is there anything else you want to say about first-pass metabolism and why it's more dangerous to give them orally?

Dr. Pam Smith  21:03
Well, some hormones are fine given orally, like progesterone. DHEA and pregnenolone can be, but particularly estrogen never should be, because when it's given orally, there is an increase in clotting. People can have a blood clot, a pulmonary embolus, etc. That trial has been done several times. When you give estrogen orally, it's inflammatory. Every disease you can get after 45 is inflammatory in nature, including memory loss. When you give estrogen on the skin, it's anti-inflammatory. It decreases inflammation. And then, of course, there are many other reasons why estrogen should be on the skin. But a really big one is the following: It lowers growth hormone, the hormone that keeps you young, if you take it by mouth. So if you want to stay healthy, put it on the skin. 

Dr. Pam Smith  21:53

When it comes to testosterone, it has to be on the skin because with the oral version, methyl testosterone, there is an increase in cancer of the liver. So we do want the liver to be healthy. But newer information is also showing that part of estrogen is broken down in the gut, so we can now measure that. There is a test to measure estrogen metabolization in the gut. So is it important for the gut to be healthy? Yes. You are the expert in the area of gut, Jill. Truly, if the gut is not healthy, the patient is not healthy.

Dr. Jill  23:00
And this is great to know. And since we have no… We can say anything if you want to share. What is the test for the gut? Is it a commercial laboratory or something that physicians can order?

Dr. Pam Smith  23:12
It is. It's called BiomeFx testing. 

Dr. Jill  23:14

Oh, yes.

Dr. Pam Smith  22:41

So it's right on that test. It's a fabulous test. It's made by [inaudible] Lab. They are right outside of Washington, DC. They actually do some of the blood work for the White House, no matter who's sitting in the White House. It's a fabulous stool test to look at how the gut is functioning. But there's literally an estrogen breakdown test on there.

Dr. Jill  23:08
Wow. So this is so funny. Right here, sitting beside me, I just recently got it because I was checking out the company and have not looked at the results. So guess what I'm going to be doing after this call? I'm going to dive in. I literally have my results right here, hot off the press. I'm like, “Oh, that's amazing!” So I will be learning right alongside that. 

Dr. Jill  23:26

I don't think I'll put you on the spot because you are so good with details and stuff, but I'm curious. I had breast cancer at 25. I had ER/PR negative and HER2 positive, which is very aggressive. You know, but for people listening, it means the cells were mutated way away from the normal kind of healthy cells that have estrogen and progesterone receptors. So I was not a candidate for hormone therapy because the breast cancer cells didn't have hormone receptors on them. And I had three-drug chemotherapy.

Dr. Jill  23:52

I know now that there are so many things, like chemicals. I had a silent celiac. I had massive inflammation and lots of things. I had grown up on a farm with atrazine, which is a known endocrine disruptor—probably in utero exposure from my mother because when you get cancer at 25, you probably have the cells that go bad at like 10 or 5 or way before that age. So you and I know a lot about these pathways and how it kind of makes sense. 

Dr. Jill  24:19

This year is 20 years since my breast cancer diagnosis, so it's amazing. I feel like, hormonally, I'm in the best shape of my life. I'll tell you what: I feel like even though there's probably not another doctor out there that would say, “Jill, you could take hormones,” I know if I wanted to do that, I would feel comfortable monitoring and doing that. I'm curious if you'd be comfortable saying if someone like me, who has that history but also knows and actually monitors things like 4-hydroxy estrogens, which we can talk a little bit about… That's the type of estrogen that Dr. Smith was mentioning that can come down this pathway and damage DNA. So that estrogen is really, really high, which in the past it was, [but] now it's not because of the stuff that I've done for detox. So my question to you is—I'm 44—would you consider giving me hormones if we monitored them as a breast cancer survivor?

Dr. Pam Smith  25:12
That's a great question. Even OB-GYNs now that are traditionally trained have looked at the idea that 20 years is the draw line. If you are cancer-free for 20 years and you've had breast cancer, then we do consider hormone replacement natural, at the lower end of normal. And that is for heart and brain protection. Because at this stage, at 20 years, there's an increased risk of having heart disease and cognitive decline, which outweighs your risk of getting breast cancer again.

Dr. Jill  25:46
Oh, I knew you'd have a beautiful answer. I'm so glad I asked, even for me. Now I know I'm comfortable taking that risk if I were to choose, but I'm curious about another professional and what they would say to me. And that's brilliant, because I did not know that that was the kind of data. And I have had those discussions. What I typically do is, one-on-one with the patient with informed consent, say: “Hey, there's some risk. Here is what it is. Let's monitor it.” But I didn't realize there was a 20-year cut-off. So I just hit that golden mark. Yes. 

Dr. Jill  26:16

And I'm assuming, just like for anyone else, you would test every six months and monitor that 4-hydroxy. Is there anything besides the 4-hydroxy that you would watch in someone who had had previous breast cancer? [Is there] anything else that you would think about in someone like myself?

Dr. Pam Smith  26:30
Yes, because 16-hydroxy—you need a little bit for bone structure. Too much increases your risk of breast cancer as well. And I do want to measure the entire methylation pathway. I have not had breast cancer, but I have a very strong family history. On my mother's side, I never met my grandmother. She died of breast cancer during World War II, so before I was born. I have a cousin on that side who never had children, which is a risk factor for breast cancer. She died of breast cancer at 51. On the other side of my family, I had an aunt who got it and died of breast cancer, [and] another aunt who got it and survived. Both of them drank alcohol. 

Dr. Pam Smith  27:14

The new studies that are out now show that you can very much mitigate your risk factors if you have a family history like mine. Number one: Women metabolize alcohol at a much slower rate than men. So for people who drink alcohol, one drink a day is max for women because of our slow metabolization. [If you have a] family history like mine, you shouldn't drink at all. And if you ask me, am I a teetotaler? I am because of my family history. I don't drink at all. And the American Cancer Society came out very recently and suggested that women should consider not drinking because it is a risk factor. You have to mitigate them. 

Dr. Pam Smith  27:58

And do I want to look at homocysteine and the rest of the methylation pathway? Yes. So 50% of people don't methylate well. For those of you who don't know what that is, it's putting a CH3 group on a pathway so that they not only go through methylation but through detoxification and the transulfuration pathway and then into the other side of that pathway for energy production. I have high homocysteine. So, of course, I have a family history of heart disease. My dad had his first heart attack a week before he was 45. [I have] a family history of breast cancer. 

Dr. Pam Smith  28:36

Of course, I had high homocysteine. But fortunately, I have known that for 29 years. So at that time, the only test that was available was methyltetrahydrofolate. Looking at that measurement through homocysteine, the reductase part of the whole pathway was not available. I started taking methyltetrahydrofolate 29 years ago. My homocysteine is normal and has always been. But now we can look at the whole pathway—all of it. So can we do a lot—yes, absolutely positively—to mitigate these risk factors? Because many people have them.

Dr. Jill  29:12
Yes, that's exactly how I feel. I feel like over my 20 years, that's been my education: How do I fix the pathways that were dysfunctional back then and do the detox? So [there are] things that I often think about with hormones, and I would love any comments you have: Glucuronidation is a pathway through the gut and estrogen. So often, if beta-glucuronidase is high in the stool, you can give calcium D-glucarate to aid that pathway, and that can help with hormone detox.

Dr. Jill  29:34

As you mentioned, methylation is key. And in some of the urine metabolite tests and, of course, some of the blood tests, you can see the pathways and the different metabolites. You can basically infer which ones might need more support. And those types of things would be methyl B12, 5-MTHF, which is methyltetrahydrofolate, as Dr. Smith mentioned, and then B6 or P5P and riboflavin. Those are all pretty important in that pathway.

Dr. Jill  30:00

Other things: DIM is really important. Yet I find that postmenopausally, I think that can be too much. And it'll actually turn things the other way as far as osteoporosis. So I'm more careful about how much DIM I give postmenopausally. Any comments on those? And then, of course, we could talk [about] glutathione, NAC. What are your favorite nutrients that you want to make sure that patient has for the detoxification of hormones?

Dr. Pam Smith  30:23
Well, I actually like to measure. I measure everything, so it is a customized approach. Not all my patients are on DIM. If there's a problem with the COMT pathway, etc., then great—there are many ways to fix all of these pathways. So I do measure them in every single patient. That includes gut health as well, and looking at beta-glucuronidation. The science is here. 

Dr. Pam Smith  30:50

What we probably should also mention is melatonin. Melatonin is not just for sleep; it's part of the immune system. It's made in the pineal gland in the brain, but it's also made elsewhere, particularly in the gut. Melatonin is a key component for the immune system. We actually treat stage four breast cancer and other kinds of breast cancer with melatonin, with or without chemotherapy. And they are getting very, very good results. So there are a lot of different ways of mitigating these pathways. 

Dr. Pam Smith  31:25

The other thing is, please, everybody who's on today: Do not go out there and take methylated vitamins. You can over-methylate and increase your risk of getting cancer and other diseases. So we have these tests. Please come see a functional anti-aging practitioner, and please come have it measured. Come see a compounding pharmacist and determine: Do you need methylated vitamins?—because we don't want you to over-methylate either.

Dr. Jill  31:55
Right. And I find that if you're super toxic for other reasons and you don't know it, and you all of a sudden just replace all your methylated B's and [do] all your detox, you can really overdo it because your body can't handle it. It's almost like you're mobilizing toxins, and you can excrete at that same rate. So I find [that for] people who are very toxic, you have to go very slow on these processes or you tip them over. It's a bell-shaped curve, and you can throw them right over the roller coaster bell-shaped curve into overload—overmethylation. And if you're overmethylating, you can have anxiety, insomnia, and agitation. Even diseases like bipolar [disorder] and schizophrenia can be parts of these pathways, so just be careful. 

Dr. Jill  32:35

So maybe in the last 10 minutes or so, let's talk a little bit about [how] right now we have access to these kinds of hormones—basically individualized protocols—where we can compound exactly what the patient needs based on testing and then change it if needed and do it transdermally or for progesterone or DHEA, maybe orally. How we first started this conversation is that compounding pharmacists for us is key. They're part of our toolbox. So what is the risk with our compounding pharmacies? And what do people need to know to be advocates for this tool that we have that we could lose if we're not careful?

Dr. Pam Smith  33:13
Well, it's important to understand that compounding pharmacists have specialized training. They're not just pharmacists. And people who go to school now are actually PhDs in pharmacy, called pharmDs. They have a lot of education. But compounding pharmacists have even more. They take additional training to learn how to actually make hormones and skincare creams—not just for “hey wrinkles,” but [for] psoriasis and rosacea. They make many other things. They also make different kinds of chemicals for people who may not be able to take something over the counter because they have an allergy. So all these reasons. Sometimes it needs to be in a different base. There are different bases you put hormones in, for example. So they actually do get into the skin. 

Dr. Pam Smith  34:04

So how do we know if it's made right? People always ask me that. Number one, do they have training? They do, and they have updated training all the time. But you can always send off anything—hormones or anything else—to Eagle Laboratories or any other outside lab and have them analyze what is being made so we know it is very safe. We know it is very accurate. And I do send it off now and again. In my personal practice, I use 11 different compounding pharmacies in six different states. And now and again, I do send it off just to make sure of its accuracy. So far in all these years, I've never had anybody be less than 98.7% accurate, and most people are over 99.5% accurate. So when people think, “Oh, it's just made in a back room,” that's not true. There are sterile hoods. There are all kinds of things. There's training, and there are checks and balances. But I love compounding because it is personalized. And that's where medicine is in 2021. The science is here for a personalized approach.

Dr. Jill  35:14
Thanks for sharing that, because a lot of patients just expect us to get what they need and take care of it, which is fine; that's what our job is. And this is funny because we're transitioning to an EMR, and I'm like in the dark ages because I still have my paper [charts]. I love my paper charts because I can flip through. But all that to say, one of the hindrances to that that's been the most difficult is that for most patients I see, I might have four prescriptions in four different pharmacies—because “I know this one does really good at this and is at a good price,” “I know this one does B12,” and “I know this one does… ” And I know those.

Dr. Jill  35:46

just like you, I have my book of pharmacies that I know and trust, are accurate, do a great job, and have good prices for the patients, depending on the state of the patient I'm seeing. So there are a lot of things that go into that, [along with] you and me having the knowledge to know, trust, and pick the right pharmacies. All that to say, patients may not know that number one is that we rely as physicians on these experts who have training to get the tools we need to help the patients. If today we lost our ability to have compounding pharmacies, it'd be like my hands were tied. Right, Dr. Smith? Literally, it would be like practicing blindfolded with our hands tied behind our backs, right?

Dr. Pam Smith  36:26
It would be terrible. Let me give you an example. I said earlier that I have normal testosterone, so I do need DHEA, as most people would in my age group. Because I have normal testosterone, or if you have high [testosterone], you need the keto form of DHEA. That means they put a keto group on, and it breaks down into estrogen but not a lot of testosterone because you already have it. One of the first things that they're trying to take off the market is the ability to compound keto DHEA. That would be a disaster for me. I would have terrible acne because my testosterone would go up. It would be a disaster for my patients as well. 

Dr. Pam Smith  37:05

Now, some people can get keto DHEA without a prescription. But the trouble is that the doses are usually very large. I only take one milligram of keto DHEA—just one milligram—otherwise I get acne. If there wasn't the ability to have it compounded, then I would not have the same energy and brain power without the DHEA because I would have a hard time taking it. I'd probably have to buy it over the counter, open it up, take a lot out, and close it back up, which would not be [inaudible].

Dr. Jill  37:38

Dr. Smith, the ones I know start at 25. So, can you imagine?

Dr. Pam Smith  37:41
Exactly! I could literally [inaudible].  

Dr. Jill  37:47
[inaudible]. Absolutely. And like you said, we didn't talk today about mast cell activation. But I see a ton of patients who are incredibly, exquisitely sensitive to the environment. So I need to compound minuscule doses just like you mentioned, or very specific… Ketotifen—we can't get commercially. That's a mast cell stabilizer. [It is] really critical to a lot of my mast cell patients. So it's not just hormones. So is there an action, or is there a link I could share? Anything that I could share for anyone who's interested in taking action and just speaking out about the value of this? Is there anything you can give us for resources so that we can have our voices heard?

Dr. Pam Smith  38:24
Absolutely. I can send you a link. Please share it with everyone, because we'd love to have your story. So please share it. We'd also like you to contact your congresspeople, both in the Senate and in the House of Representatives, because they do listen to their constituents. And let them know how important it is for you, your friends, and your family to maintain the ability to have compounded hormones and everything else. 

Dr. Pam Smith  38:51

One of the hardest things to make in the world is compounded thyroid. But at least 40% of my patients are on compounded thyroid. For two reasons: One, everything over the counter is either T4 only and the body makes T3 and T4 or it's a desiccated thyroid, which is four parts T4 to one part T3. That ratio is not perfect for every single patient. But a compounding pharmacist can make it any ratio we want it to be, [such as] 1:1, 20:1, or 10:1. And then the patient has the perfect amount. Also, there's one study showing that if you have Hashimoto's thyroiditis, which is an autoimmune hypothyroidism or autoimmune disease—most patients who have it are hypothyroid, meaning low thyroid function—then you shouldn't be on desiccated thyroid. You should be on non-porcine. According to clinical trials, 98% of people need T3 and T4. There would be no other way of getting that besides compounding.

Dr. Jill  41:01
Yes, thank you for mentioning thyroid, because it's a whole other issue and a lot of patients are dealing with that. I'll get that link. If you're watching on Facebook, that will be added. If you're watching on YouTube, that will be below in the notes. And if you're on the podcast, I will put that in the show notes. So anywhere you see this podcast, you can find this information. And please, please help us by putting your voice out there, because this is going to be critical going forward for us to do our jobs in personalized medicine. This was the main reason why I wanted Dr. Smith to come. And among that is all the other amazing knowledge that she shares. And as you can tell, it's such good, concise information based on research. She's a scientist at heart. Anything else that you want to leave us with as far as hormones, hormone replacement, or what we can do to be advocates for ourselves?—for patients or physicians.

Dr. Pam Smith  41:53
Yes. From the viewpoint of hormones, it's important that you measure them. And I think this has been part of the problem when it comes to looking at hormones going away: Not all doctors measure. Please make sure that you see a physician, nurse practitioner, APA, or pharmacist who is fellowship-trained. They actually have training in this area. That is a fellowship attached to a medical school. They didn't just come up with a dose from anywhere. They didn't take a one-day course. Make sure that you see someone who is really an advocate for you in a personalized medicine approach, and they took the time and effort like Dr. Carnahan did to actually become a fellowship trained in this field and be a wonderful prescriber and patient advocate.

Dr. Jill  41:45
Thank you for saying that, because maybe one of the biggest questions I get is: Where can I find another doctor like you or Dr. Smith? Is there a website or place? I know that we both worked with A4M. Where would you recommend people find the training or doctors that are trained in this?

Dr. Pam Smith  42:00
I will send you a link to that as well, so you'll have two links to this.

Dr. Jill  42:04
Perfect, we'll add that on. Fantastic. Thank you so much, Dr. Smith, for sharing your knowledge. I've been seeing the feed and the questions, and I know it'll just continue with the viewers. Thank you all for listening today. If you have any questions, put them in the box. I will come back and answer them in the future here. And if you want to find more of our videos, you can find me on YouTube at Jill Carnahan—the playlist there. Please subscribe because you can get these and all the rest that are there for free. It's free content. And we'll be back next week for more. Thank you so much.

Dr. Pam Smith  42:36

Thank you so much.