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Maria Mackey

Have you ever wondered about the complexities of women’s hormonal changes during perimenopause and beyond?

In today’s episode, Dr Maria Mackey joins us to discuss the functional medicine perspective for treating Perimenopause and beyond.

We explore the decline in estrogen and progesterone production, its symptoms, and its relationship with serotonin production. We also shed light on assessments used to detect hormonal drift and the role they play in prescribing decisions. Finally, we discuss hormonal imbalances in post-menopausal women, treatments, and lifestyle changes. This episode is a deep dive into women’s hormonal health and is a must-listen for anyone navigating this complex transition.

About Dr Mackey
Dr Maria Mackey graduated from Otago University, Dunedin, New Zealand and has been practising medicine since 1994 in Australia. Dr Maria has been practising “wellness” medicine since 2002, after completing a Diploma of Homeopathy in 2000.

As one of Dr Maria’s patients, you will get up to date with the latest integrative medicine management strategies that may regain your health and may assist with getting your “Mojo” back.

Dr Maria is passionate about utilising her knowledge of integrative medicine for prevention. Her drive is to empower others to own their health through improved awareness and knowledge, Therefore educating them about healthier lifestyle options that may make them feel better.

Connect with Dr Maria
Mojo Klinik



Andrew: Welcome to “Wellness by Designs.” I’m your host, Andrew Whitfield-Cook. Joining us today is doctor Maria Mackey, an integrative physician, who’ll be giving us a medical perspective on the functional approach to women transitioning through the perimenopausal period and beyond. Welcome to “Wellness by Designs,” Maria. How are you?

Maria: Hi, Andrew. I’m very well, thank you.

Andrew: It’s great to be chatting with you once more. It’s been so long in between visits, in between chats. Now, Maria, for our listeners, for those people watching, could you take us through just a little bit of your history and background please?

Maria: Sure, Andrew. So, I’m a medically-trained doctor. Graduated from medical school from the University of Otago in December of ’93. So, coming up to nearly 30 years of having been a doctor. I’m currently located here in Sydney, Australia. I’ve practiced my whole time as a doctor here in Australia, between Sydney and the Gold Coast, where we happened to meet, as I was newly sort of introduced to integrative medicine. And I think the thing for me has been trying to find a way to help my patients through whatever it is that they come to, to me. So, there’s my medical training on one side, and then I’ve done a lot of postgraduate training in integrative and functional medicine in between all of that time frame. Yeah.

Andrew: So, take us through a little bit of that introduction to integrative medicine, because it’s a big jump. It’s a big hoop to jump through, when, you know, you’re coming from that orthodox paradigm, isn’t it?

Maria: Very. So, when I first started doing this, I was seeing teenagers with chronic fatigue, on one side, and then I had menopausal women that were flushing like mad on the other. And, at that time, it was very difficult, because all I knew was to prescribe, you know, our traditional medical treatments, and that was, we’re talking in the ’90s and the early 2000s. So, in those days, it was predominantly a pill-based hormone replacement therapy program. And at the time, I think compounding was still fairly in its infancy, and a lot of the time, women were being prescribed troches, which I had no idea about. So, I had to hurry up, go off and start learning about, you know, what’s going on. Because, from a medical perspective, we have symptoms, and then we have a medication. And then the medication does not, you know, fit all. It doesn’t work for everyone. And this was pre-WHI, you know, before the big study that happened, which showed us the dangers of prolonged oral hormone replacement therapy. So, it was an extreme of dealing with very tired youngsters, which I’d never been trained to deal with, and then on the other side, having women, you know, getting towards the end of their reproductive cycle, with hot flashes, mood swings, and the whole gamut of what goes on with menopause.

Andrew: Was that a big challenge for you, though, to embracing the integrative model, or was it like, “Hell, you know, I’m not, this isn’t working, so I’m open to anything?”

Maria: It was a transition. You know, it was initially very difficult to put aside my medical training, to learn a new ethos. I’d started learning some traditional Chinese medicine before I got into any of this, and that really rang my bell, because I was working in a hospital, I was learning about TCM principles, and point location, and how to acupuncture, you know, points. That time, I found it very difficult to change gears.

Andrew: Right. Okay. So, on to our topic for the day, and that’s perimenopausal, that perimenopausal period, forgive the pun. So, can we go through some physiological changes? What’s normal, what should happen, and what are you seeing in your patients? What’s going wrong?

Maria: Well, it starts, as women, as girls, we don’t have any… Well, we do have hormone cycling, but reproductive hormones, it’s all one bandwidth. And then you go through puberty. And then our cycles kick in. Now, from then, the ovaries have a set time frame upon which they’re going to work and produce hormones. So, the main function of our reproductive system as females is for us to make eggs, you know, conceive a baby, carry it, and then pop it out, and along the way, we have this cycle of changes that occur in our reproductive cycle. So, by the time we get to our 40s, our ovaries are starting to get tired. And they’re not up to producing the same level of hormones as what they do. And so, what you see is a hormone drift. There’s this gradual decline in hormone production, across the board. And from that we get a whole array of symptoms that appear, for some women. For some women, they don’t. Those are the women I don’t see. The women that have problems are the ones that I do see, and I tend to work with.

Andrew: So, there tends to be, or there’s going to be this population, which, as you say, you don’t see. They’re the women that are quite well-handled, either without any medical intervention whatsoever, or they’re happy with the medical intervention. So, looking back on your earlier days, what percentage of women were happy with either none or medical intervention versus those that were really not well-handled, and were seeking alternatives?

Maria: I think there’s a bias, because what happens is that those women that are happy, they’re sailing along quite nicely, and you only meet them as a by-the-by. Something else happens, and they happen to be, you know, visiting for another reason, I spark up the conversation about periods, menopause. And those women, they would say to me, invariably, “Oh, you know what? That’s fine. No, I don’t have any hot flashes. I’m sleeping well.” I’m talking about women that are 5 to 10 to 15 years post-menopause. And then I learned to ask, “What was your mum’s menopause like?” And then they would tell me, “Oh. My mum was fine. She had no problems.” And they’d always got me. I was like, “Hang on. Wait a minute. That’s not common. What is it about those women that’s okay, and then I get the others that come to me and it’s like all hell’s breaking loose, because their hormones are starting to change?” So, they’re out there. It’s just my practice is biased because by default, I’m gonna get individuals that seek me out, you know, to help them resolve an issue.

Andrew: Yeah. And so, what have you discovered with that mother-daughter genetics, intergenerational stress, behavior? Like, what are we talking about here? What’s the main factors?

Maria: It gets really fascinating. So, one of the clinical observations that I made in women with premature menopause, so, that’s where their periods have stopped way ahead of their time, I’m talking in their 30s, you know, late 30s, or actually even early 30s, I learned to ask, “What was your pregnancy like? Have you asked your mum? Do you know what happened during that time frame?” And they all tell me, hands down, “Oh, my mum’s pregnancy was very, very challenged. She was extremely stressed.” And they… Or something quite marked had happened. So, you know, I was quite intrigued by this, this sort of impact of emotional stress on women that are pregnant, and what happens, you know, with their babies and their outcomes. And there have been studies done on this that look at maternal stress and fetal outcomes, and but invariably, my observations have been the more stress the pregnancy, the more stressed the bub. If they’re girls, they can have problems with how their ovaries and adrenals and their hypothalamic pituitary axis works. It’s an HPA-ovarian axis issue, if that makes sense.

Andrew: Right. Yeah. And so, obviously, there’s also the issue of, I mean, this is a whole nother podcast, really, it’s a whole nother topic, but the issue of the drugs of the day that we used in pregnant women to handle symptoms, things like DES, diethylstilbestrol, that, wasn’t them that had the issues, but their daughters. There’s a whole tin of worms to open there. But you mentioned earlier, a hormonal drift…

Maria: I’ve had patients with that scenario. Yeah.

Andrew: Oh. Okay. So, you mentioned hormonal drift.

Maria: Yes.

Andrew: Can we discuss that?

Maria: Yeah, sure. So, with declining ovarian function, you get a drop in progesterone production, primarily. That starts first, and it can happen in the late 30s, early 40s. And with that can come a little insomnia, sleep disruption. Reproductive hormones have an impact on sleep patterns. Estrogen does. Progesterone does. And so, there’s this sort of increased sensitivity to stress when progesterone levels drop. It stimulates the GABA receptors in the brain, so it helps to relax us, and also to help us just with sleep latency, so that we get a better quality sleep. So, there’s this increased sensitivity to stress, not sleeping so well, and then, once estrogen levels start to drop, that can have an impact on mood, and it can present with anxiety and/or depression.

Andrew: And then, of course, we’ve got the, you know, the other issues. We’ve got maintenance of bone strength, skin elasticity, vaginal dryness, da, da, da. Do you wanna talk about what you mentioned first, or do you wanna go into the other?

Maria: So, I’ll use an example. We’re talking about perimenopause now. Perimenopause is a time around menopause. So, menopause, by definition, is 12 months no period. And so, that perimenopausal time frame, we used to think could have been, like, 12, 24 months prior to their period stopping. We’ve now since realized that that onset can start as early as your, like, early 40s, and can present with something as simple as depression. And once upon a time, well, actually, at present, the management for mood changes where depression is clinically relevant and diagnosed, antidepressant medication is often used. And one of the things that we’ve come to realize in mainstream is that that’s not necessarily an appropriate treatment for a perimenopausal female. And she may benefit from hormonal supplementation.

So, that’s been a huge change in the, sort of, the tonality of managing menopause and mainstream medicine. And it’s being championed by the Australian Menopause Society at present, and we’ve got some really cool endocrinologists and gynecologists that are promoting the early recognition of early onset of premenopausal symptoms. And those perimenopausal symptoms are due to that hormone drift. Across the board, you’re getting the slightly decreased production. Ovaries have been popping out eggs every cycle. They’re getting tired. They don’t work as well as they used to. And so, that’s what we’re seeing. And, you know, you’re talking about an array of symptoms that can come. So, predominantly with mood, that drop in estrogen leads to what we think is a drop in serotonin production. Estrogen helps to buffer serotonin production. And so, if you don’t produce as much, you don’t make as much, and it can get really tough for these women, you know. And what they’re typically being offered is an SSRI, or an SNRI, to help them with that mood. Whereas judicious use of topical estrogen, cyclically, along with a progesterone, as a synthetic, a body-identical progesterone, may be of better value for that particular person. Yeah.

Andrew: So, it seems to me almost like that positive feedback issue with pregnancy, that, you know, when the placenta is engaged, when prostaglandin is engaged to start the birth process, that it’s a positive feedback cycle. Similarly, you were saying when estrogen is low, it causes lower estrogen. Is that correct?

Maria: So, what I’m talking about is ovarian reserve. We talk about the ovaries’ capacity to produce eggs, but we also need to consider the ovaries’ capacity to produce hormones. So, what happens is that, with declining ovulation, so, every cycle, from menarche, from the time that a woman has begun her periods, there’s a set number of eggs, and a certain number are going to complete and ovulate, and a certain number are going to undergo what we call attrition, or they’re going to get, not recycled. They’re just absorbed. So, we have a set number. And, for example, progesterone. We need to ovulate in order to produce progesterone. So, if in your 40s, you start declining your estrogen production, because your ovaries just can’t produce the same amount, and you’re not ovulating as regularly, right? You’re not ovulating as regularly, you get a decline in progesterone production, because it’s produced by the sac that will pop the egg during ovulation. And so, you have what we call an anovulatory cycle, or no progesterone. And that becomes increasingly common during your 40s. A woman at 40 produces about 20% to 25% testosterone as what she did in her 20s. So, that’s gonna have an impact on libido, drive. And I’m not just talking sex drive. I’m talking mental drive. Some women have male-differentiated brains, and they require a certain amount of testosterone to help drive their brain. And it’s something that I see quite frequently. So, that may present…

Andrew: This is…

Maria: So, that drop in testosterone may lead to a lowered, or, like, absent libido. And that can cause problems in relationships.

Andrew: Yeah, absolutely. And when you were saying there, drive as well. So, not just sexual urges, but mental capacity, is that what you’re alluding to?

Maria: Correct. Correct. Yes.

Andrew: Right. So, that, combined with the issue of pre, do I say that word, prescribing SSRIs or SNRIs, what assessments can a doctor do, can anyone do, that would allude to an issue with hormonal drift earlier on? What should we be looking for? When should we be looking for these changes?

Maria: So, that’s a really good question, Andrew, and there’s no one definitive test in medicine. We’re being discouraged from checking FSH and LH, and doing hormone panels. I tend to do that. I tend, out of habit, to do that, because I’m curious. Some of the gynecologists will look at an FSH/LH, and they can tell from where that patient is in their cycle whether or not they’re starting to undergo perimenopause. And I think, sort of, general medicine, general practice, is being dissuaded from doing that type of testing, and…for various reasons. However, I think if you’re familiar in this area, and you can look at the numbers and recognize what’s appropriate for where a woman is meant to be in a cycle, you can call it pretty easily. You can match that symptomatology up with their age, and with what their numbers are looking like, and give them some guidance that way. I think it’s an area that is going to undergo somewhat of a renovation in medicine, and that a lot of doctors are getting trained how to recognize and help women that are going through that struggle, and how to use these with or without testing. Yeah? So, matching the clinical scenario, and treating that, I think that’s what’s happening.

Andrew: Right. Okay, but…okay. So, look, I understand the issue of healthcare costs, healthcare dollars, you know, can only go so far. We wasted millions and millions of dollars on far too many vitamin D tests. I understand that. I can understand the restriction for that. I don’t necessarily understand the restriction that was placed at the same time on B12 testing, but anyway. But I get responsible restriction of testing, and I’ll ask you this in a second, because it really puts you in a difficult position with over-testing in the face of Medicare, but when it’s appropriate, when you can’t really tell what’s going on with the woman’s hormonal cycle without doing some sort of hormonal testing, and combine that with what you said earlier about women were just given SSRIs or antidepressants when they really should have been given a hormonal supplement or augmentation, if you like, where does that sit with responsible prescribing? It’s sort of like…

Maria: So, the thing here is that, if you can match that age group, that demographic, and all, everything lines up, and you think, “Okay, this is clearly a perimenopausal woman. I’m going to try some cyclical hormone therapy,” this has been done before. This is not new. It’s new to us, but it’s not new. It’s been done in Europe extensively. So, many years ago, whilst doing some anti-aging training here in Australia, I was very fortunate enough to be in the audience and listen to a Belgian, a French-Belgian doctor, talk about cyclical hormone replacement therapy for women in their 40s. And at the time, I thought, “Wow, this is really cool.” However, I found that my patients, that cohort of patients in their 40s, they found taking estrogen during their cycle, stopping it when they had a period, and starting progesterone for the last 14 days of the cycle, they found that cumbersome. But I think what’s happening is that there’s this huge shift. We’re talking, now, 10, 12 years later. There’s a generational shift, and I think women are now wanting something that resonates with their biorhythms. And so, I think you’re going to get better audience participation. You know, I think they’re more likely to try that treatment, cyclical progesterone.

For example, when I sat in my GP exams, back in 2015, I was reading something around periods and cycles and hormones in women in their 40s. And in a “check” magazine, which is what GPs read, it advocated the use of oral micronized progesterone, day 14 to day 28, for women with PMS. I nearly fell over, because I was like, “Why aren’t doctors doing this?” And it just takes time for that information, that clinical importance, to filter through. And I’m seeing more doctors doing this now. And the thing is, you can do this very, very easily, without having done any tests. You just pick. You know, a shift in moods. Their PMS is getting worse. Their sleep, they’re getting insomnia, that week prior. You know, it’s pattern recognition. You can do this without doing tests quite easily. So, there’s this thing of testing, over-testing, and integrative and functional medicine, and whether you’re a doctor or a naturopath, we’re used to looking at numbers. We’re used to weighing these things up. But I think it’s really important also to look at the person in front of you, and match the clinical scenario with what you know. Yeah.

Andrew: Always. Yeah. Always. Thanks for taking us through that. It’s just, it’s so important when, you know, we’ve got this specter of over-assessing, wasting so many hundreds of dollars, that, of patient, you know, that this is patients’ income that they could have used on treatment, and you can waste so much on testing that won’t really get you anywhere, and it’s gotta be relevant testing.

Maria: I’m all for testing that’s gonna change your management. That’s how I was trained in New Zealand. It was that, and don’t prescribe antibiotics just for a flu. Thirty years ago. I know, it’s funny. The, you know, I think we need to be able to help the patients just from recognizing those things in front of us. And I think the majority of practitioners do very well with that. I’ve certainly seen that with the early onset or use of herbs, for premenopausal symptoms, you know. Along that cluster, it would, you know, it’s not just also mood changes. It can be early onset of hot flashes. You know? And women are still having their period every 28, 30 days, or, you know, whatever it is their cycle length is. The brain fog that can come, you know? So, we go through our 40s, the hormones drift, and they start to drift down, and we see more and more of a clinical scenario of what happens, sort of acutely pre, during, or post menopause. Right? And so, we get the mood changes, we get the hot flushes, we get the weight gain, we get that terrible insomnia, the brain fog. You know? Where they use that “whatchamacallit?” You can’t find the right word to describe things. The physical changes, like bone changes, they come down the line, you know. But they need to be considered, most definitely, when you’re having a chat with a woman going through these changes. Yeah.

Andrew: Gotcha. Right. And so, two treatments. You were mentioning herbs before, and the natural armamentarium of non-medically-trained practitioners is to use herbs and nutrients and diet and lifestyle, things like that. Tell me about, tell us about, what’s your experience with efficacy versus bang for buck, and what choices are available to you as an integrative doctor?

Maria: So, we have an array of over-the-counter preps which patients readily try, and they’ve usually tried most of them by the time they get to me. And they invariably work for a period of time and then they stop working. And they stop working because we get the hormones, you know. A typical Promensil. Or a herb that stimulates the estrogen receptors, for example. I find, typically, they’ll work for two years, and then it stops. And so, the patient will find they’ve, you know, got something that works really well. And then all of a sudden, those hot flashes start coming back again. So they go back to the pharmacy, they try another product, it works or doesn’t work, and I find that the only sort of variety of herbs that tend to hold severe symptoms for a period of time, they honestly tend to be the Chinese herbs. And it’s combination therapies that tend to work better for patients. So, and it’s working on that energy interface. But I find, invariably, if they’re using a single, a herbal treatment, doesn’t last long. And that’s because the hormone receptors get down-regulated, and the herbs can’t attach anymore, so they lose their efficacy. And in some cases, even the Chinese herbs don’t work. And so, we’re like, we’re looking, well, we’re looking at a completely, you know, looking more, like, at hormone therapy.

Andrew: Gotcha. I have seen with these red clover extracts that they contain the precursors to the more active hormone derivatives. And so, what I’ve experienced is, I always ask them, I say, “How are your guts? How have they been throughout your life? Have you had lots of issues?” Now, I get that most people are gonna say problem. And particularly as we get older, our guts take over conversations. I understand that. You spoke about bias. I get that. But it certainly seems to me that these ladies have had ongoing issues, and I wonder, I’ve never looked at this biochemically, I wonder if they might also be having an issue converting these precursors into the actives. Maybe their, you know, diversity isn’t the right type, or, you know, the bacteria species, whatever?

Maria: That is a really good point, and I have not come across anything around that.

Andrew: No, I’ve never.

Maria: When I first got into treating postmenopausal women, so, they already had the nasty hot flashes, that’s when I lived in southeast Queensland, and those Queensland women are tough, you know, but they would come in, just flushed red, and sweat dripping off them, you know, having these absolute awful power surges, and extremely uncomfortable. And I was taught to do a six-week express detox on them, from scratch. And they would come back six weeks later, and they’ve done their tests and they’ve made some dietary changes, and they go, “Oh, my god, doc. Your name was mud for the first two weeks, but now I could kiss you. I feel absolutely bloody brilliant.” You know, and majority of their symptoms had gone, and they felt like new women. So, it was incredible to see just what cleaning up lifestyle factors did for the majority of these women, you know? It amazed me. And even now, I try to get them to take the grog out, take the caffeine out, clean up their diet as much as possible, and it’s an epiphany for those individuals that are game enough to do that, as to what they’re doing to themselves on a regular basis, and what their body’s been trying to tell them.

Andrew: How does trying to take alcohol out of an Australian, particularly a southeast, like, Queensland woman? How does that work for you?

Maria: Well, they’ve suffered enough by the time they’ve usually gotten to someone like me, so they’re prepared to do anything.

Andrew: Yeah. I was going to ask a question there about those hot flushes. I appear, you know, again, have I really noticed this previously? The vernacular that we used two decades ago was that the heat came from your boots, and worked its way up. What I’m hearing now from women is that it comes from the inside out. Are we talking about a change in symptomatology, or just a change in description? Is there any new player on the market? I’m thinking toxins here, adrenal stress, sort of…?

Maria: I honestly think it’s just a generational shift and a change in expression, because I think it was coming from the inside out anyway. It’s just, those individuals… I know the women you’re talking about, because I’ve worked with them when I first got into the business. I remember them fondly, because my gosh, they were straight shooters. They would just tell you, “Doc, that sucks.” You know?

I think it’s just a shifting of the guard. I mean, for example, back in those days, you had to almost pry it out of them whether or not their libido had been affected. And it’s, even still, now, I find women in their 60s, that conversation is uncomfortable compared to women in their 50s, and then women in their 40s, they want it all out, you know, boots and all. They want to hang it out on the line, and they don’t care who sees their knickers, in terms of talking about libido. We could just talk about libido on its own, and, you know, the impact that has on a woman’s health and relationships.

Andrew: There’s a whole nother conversation there, with the disconnect between male and female libidos as to their hormone changes throughout the life. But anyway, with regards to the Chinese herbs that you use that you find most effective, I know we can’t talk about brands. I get it. But is there any formulae that you might be able to allude to?

Maria: It tends to be those that use a combination of those old herbal formulations that nourish the kidney yin deficiency. And invariably these individuals have a kidney chi deficiency. You know, it’s yin and yang, by the time they’re getting the nasty hot flushes that they do. So, it’s those formulations that target that, I think, do way better. You know, back in the day, we used to think, “Oh, two to three herbs, we’ll be right.” “Well, old Chinese herbal formulations didn’t work that way. And I’m not a TCM practitioner, but this is just from years of observing, and the majority of them have, like, five to eight herbs, and they’re synergistic, you know. Given together, they’re incredibly synergistic. And then, there are those patients for whom they don’t even wanna know about those. “Well, they don’t work.” So, we’re looking more at using what we call body-identical hormone replacement therapy. That’s the new terminology now.

Andrew: So, you mentioned earlier about looking… Forgive me. Let me rephrase that. You mentioned earlier about being aware and possibly treating earlier, about the decline in the musculoskeletal system. When we’re talking about things like sarcopenia, bone mass, or bone density decreases, do you tend to use nutrients that can maintain the skeleton and the joints? Do you tend to employ them earlier, like, you know, the collagens, the microcrystalline hydroxyapatite-type calciums? Do you tend to use these earlier?

Maria: Well, firstly, estrogen, for women, the anabolic steroid of choice is estradiol. Not testosterone. It’s testosterone for men but estradiol for So, trying to mimic that any other way, apart from using the hormone, is very, very difficult, even with herbs. Estradiol is a wonderful hormone for women. It helps to keep your skin looking young and dewy. It helps to maintain serotonin levels. It actually helps us to maintain sensitivity to insulin. That’s one of the reasons why, as we go through our 40s, in particular, if you go through menopause and just after, you can get this thickening around the middle with women. And that’s predominantly due to, well, two things. One, a drop in estradiol, because it gives you that curve that “ooh la la.” And then, a drop in growth hormone production. So, we start decreasing growth hormone production from our early 30s onwards. By the time we hit our mid-50s, we don’t have much in the way of growth hormone. Growth hormone enables us to have a six-pack after, you know, doing abs for, like, two to three weeks, in our 20s. Whereas for women in their 50s onwards, we know that just, you know, achieving a two-pack, instead of a one-pack, is a bonus, let alone getting our waistline in. You have to work really hard to try and make up for that hormone shift, or, you know, deficiency that occurs with estradiol, just in relationship. And so, you know, if it has that impact on insulin sensitivity, it alters metabolism. So, it’s like, women go, “You know what? I can’t eat like I used to. My shape’s changed. My muscle mass, I don’t have as much muscle as I used to,” that’s all estradiol. You know? So, I’ve become an advocate of using estradiol for women, where it’s appropriate. Where it’s appropriate.

Andrew: Yeah. And, just a quick question about the appropriate dosing. You know, if we’re talking about individual women, requiring individual, or having individual needs, do you see any issues with this, you know, one-size-fits-all body-identical hormone replacement therapy? Too high for some, too low for other women?

Maria: Invariably, a woman’s response to the treatment is ultimately our gauge. We don’t necessarily monitor, or advocate the using of monitoring blood levels. Those studies have been done by the companies that have produced the hormones. And so, for example, if I’m using a topical estrogen patch. So, topical estrogen has been deemed safe for women that don’t have a contraindication. And it’s mainly used, or its leading use, is for treatment of hot flashes. So, vasomotor changes. And so, invariably, we try to titrate the estradiol level to match the intensity of that woman’s symptoms. Now, if a woman is sensitive to it, then she’ll get breast sensitivity, if she has too much. So, we’ve got to…or if we use too much, it can cause, sort of, periods, and we don’t want to have too high of hormone levels, so that a woman is starting to cycle through and get periods again. So, it’s just, it’s treading a fine line where you’re giving enough hormones, in those latter years, to meet their physiological needs, and to gain benefit from it, without tipping them into symptomatology. And you can do that quite safely without testing, needing to do blood tests. It’s not encouraged, and I certainly, I don’t do it. I don’t encourage using it either.

Andrew: And… Sorry. I was…

Maria: And so, the thing is… Yeah. If, I’ve just gotta say that if we use topical estrogen, and a woman has her uterus intact, so, she hasn’t had a hysterectomy, then we have to give progesterone to offset the risk of unopposed estrogen, so those two treatments go together. I like to give progesterone, because it helps to calm the brain down, and it helps with, you know, maintaining good sleep hygiene. And I’m talking hygiene in the context of quality here.

Andrew: And, so, when we’re giving estrogen and not testosterone, do you employ the use of certain micronutrients, like, you know, the classic one is zinc, B6, magnesium, to help run the hydroxylases, when you’re talking about conversion from the, let’s say, higher hormones to the lower hormones, like, for instance, testosterone? Do you use those?

Maria: So, my way of… So, you’re talking about using supplements as an adjunct for… It sounds like you’re trying to work on pathways. Enzyme conversion?

Andrew: Enzyme conversion. So, from, let’s say, pregnenolone to progesterone, estrogen, down the flow, to testosterone etc.?

Maria: Well, when we’re using body-identical hormone therapy, you don’t need cofactors per se, because you’re just giving the real thing. You’re just giving them right at that endpoint. You would use those nutrient therapies if you were trying to improve, sort of, neurotransmitter balancing and cascades. So, brain hormone balancing. If you’re trying to work with detox, general detox, there’s some, you know, great, you know, things we can use. Amino acids. I’m a big fan of using amino acid therapy, and judicial use of vitamins and minerals in the mix, to try and help balance out those phase-one, phase-two detox pathways. There’s some great, you know, powders of products available that can help with that.

Andrew: Oh. This is another podcast for us.

Maria: But we’re trying to give enough hormones that you’re not stressing the pathways. You’re just meeting their needs. We’re not going to mimic the entire hormone production that a woman used to produce, and would need full-capacity detox pathways to handle. We’re just trying to give enough to have a physiological effect, and calming hot flushes. And to some degree, some women can get improved cognition with estradiol. You know, I have had that occur, where some of the word finding issues are thought to be estradiol-related. So, I listened to a podcast with a very, very informative endocrinologist from Melbourne, who talked about how they were looking at estradiol being implicated, or the lack of it, in post-menopausal women, as an increased risk for Alzheimer’s. And they, the analogy used is that once your estradiol levels drop, your brain cells can’t take glucose up as efficiently as they used to, and that drop-off is by as much as 25% for some women. And that’s what they think contributes to word-finding issues, word association issues. So, they called it the “whatchamacallit syndrome.” And so, I found that really fascinating, because, for some women, once I give start the estradiol, the body-identical estradiol, not… And I’m not talking about just treating hot flashes here. But the brain function improves. Of course, I use other, sort of, nutrient therapies to augment that, to try and sharpen up how their brain is working. But for some women, it’s been an absolute game-changer for them.

Andrew: Do you know? Like, it’s almost a wake-up call for me about, instead of treating things that we are aware of… Forgive me. That just fell out. Instead of treating things that we see in front of us, for instance, like insulin resistance, pre-diabetes, and you’ll see, as you mentioned before, the weight gain, the loss of the abs, turning into one ab, and we look at weight gain, or weight control, appetite suppression, possibly metabolism, sugar metabolism, and perhaps we should be looking way earlier down the track, to hormones, the sex hormones, to help how the cells are gonna be responding to insulin and glucose and things like that.

Maria: One hundred percent. I’ll go back to testosterone, because I think I’ve talked about estradiol enough. Testosterone helps with sex drive. So, it helps with… What happens in women is that once their hormones drift, you get shrinkage of the arousal tissue, and it loses its volume. You need testosterone to help reignite the fire, all right, to help, from a libido perspective. And it helps with making it easier to orgasm. But you also need estradiol to improve vascularity to that arousal tissue in a female. So, you need a bit of both. You know, estradiol enables us to blush. And so, you need engorgement of the arousal tissue in order for it to work properly. So, women will say, look, I’ll ask them, “How’s your libido?” And they’ll go, “Zero. Nothing. No interest whatsoever.” And I’m like, “Well, how long has that been going on for?” And the answer’s gonna be two to five years. And their hormones started drifting or dropping off anywhere up to two to five years prior to that point, before you saw a structural shift. And so, if they’re seeing me at 50 or 48, they got no libido, I’ll go backwards, and go, “When did you last have one?” And then I count back two to five years, and I’ll ask them what happened around that time frame.

So, for a woman, if you draw a rectangle, 25%, and you cut it in half, 50% of their testosterone production is produced from fat, 25% by ovaries, 25% from adrenals. So, when I’m teaching my clients, I’m talking to them about where their hormones, what’s going to babysit them through their time of change. Invariably, it’s the adrenals. If you’ve lived a very stressful life, which, hey, you know what, this is modern-day living in Australia, and we all have our stresses, and we get compressed with stress, our adrenals] left, right and center. And if they’re not nurtured and looked after, your latter years can be a very, very difficult time from a hormone perspective, because normally, they would produce the hormones that would take us through smoothly from menopause into post-menopause.

Now, that’s happening less and less. I think we’re all, you know, getting affected. And I’m just talking about women here. And men are another kettle fish. And so, you know, testosterone helps us to be decisive. Women that are testosterone-insufficient dither. They vacillate. They have difficulties making their minds up. They’re the sort of patients where I’ll be talking to them about their results, and we come to the end, and I’ve recommended, you know, a number of treatments. And one of them may be testosterone, in that package. And then they’ll say to me, “Doctor, do you really think I need testosterone?” And I look at them, and I’m going, I’m thinking to myself, “Wow. If ever I could find someone who needed testosterone the most, it’s gonna be that woman in front of me.” And so, I try to find a way to translate that in a nice way. So, invariably, I’ll say, “All you have to lose is indecision.” And it’s, stop and think for a while. “Okay. Are you sure?” I’m going, “Yes. Take the testosterone, please. Do the test in six months…six weeks’ time. Come back and let’s have a chat.”

Andrew: Indecision about indecision. That’s a whole nother conundrum.

Maria: Unbelievable. And, yeah. Sorry. But they are the ones that I think to myself, “Woof.”

Andrew: No, I was just gonna say… Doctor Maria Mackey, there’s so many different aspects here. There’s so much more that we can talk about. Unfortunately, we’ve run out of time, but I can’t thank you enough for taking us through your care of patients, what you’ve learned over the years since I’ve known you, the decades. And I gotta say, it’s, there’s something going on with you, because you haven’t changed one iota.

Maria: Oh, hush.

Andrew: You’re doing something right, so obviously, you’re walking your talk. But well done to you, and well done for your care of so many women, and, indeed, men and couples throughout your time being an integrative doctor. Thank you so much for joining us today.

Maria: Thank you, Andrew. Thank you very much.

Andrew: And thank you, everyone, for joining us. Remember, all of the show notes and the other podcasts can be found at the Designs for Health website. I’m Andrew Whitfield-Cook. This is “Wellness by Designs.”

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