The clocks just fell back last night.

For most people, that means a few groggy days and an extra hour of sleep they don’t quite get to enjoy. But for a woman whose rhythm is already off, this week can hit hard. And if you’re that woman, you probably already know your pattern.

You hit a wall around 2pm. Not sleepy exactly, just done. Your brain goes foggy, you reach for coffee or something sweet, and you push through the rest of the afternoon on fumes.

Then at night, when the house is finally quiet, you can’t wind down. Or you fall asleep just fine and wake up at 3am, wide awake, mind racing, staring at the ceiling until your alarm goes off. Checking off the endless boxes of “to do’s” in your mind.

Most women think these are two separate problems. A daytime energy problem and a nighttime sleep problem. Two different fixes. Two different supplements.

They’re usually the same problem, showing up at two different times of day.

Last week I wrote about why your body won’t heal until it feels safe. This week, I want to show you what that looks like inside your body, hour by hour, and how you can actually measure it instead of guessing.

One rhythm, two symptoms

Cortisol is designed to follow a curve. It rises sharply when you wake up, so you have energy to start your day. Then it slowly tapers off through the afternoon and evening, reaching its lowest point at night so you can fall asleep and stay asleep.

High when you need to go. Low when you need to rest.

When a woman has been running on stress for years, that curve flattens. Researchers have linked flatter daily cortisol curves to poorer health in 10 of the 12 categories they looked at, with the strongest link to the immune system and inflammation. And in real life, a flattened curve tends to show up in two predictable places.

At 2pm, cortisol runs out too early. Instead of carrying you smoothly through the afternoon, it drops off a cliff. Add a lunch that spiked and crashed your blood sugar, and you hit the wall no amount of coffee can touch.

At night, cortisol stays up too late. Instead of quieting down, it lingers. Short sleep makes this worse. In one controlled study, cutting sleep short raised evening cortisol by 30%, and the free, active form jumped by 200%. Your body is tired, but your brain hasn’t gotten the message that the day is over.

The 3am wake-up often fits right into this picture. In the early morning hours, your cortisol naturally starts climbing to get you ready for the day. If your rhythm is already running hot, or your blood sugar dips overnight and your body calls in cortisol to bring it back up, that rise can pull you wide awake hours before you’re supposed to be.

So the woman who crashes at 2pm and the woman who wakes at 3am are often the same woman. Her body isn’t broken. Her timing is off.

The pearl: Your 2pm crash and your 3am wake-up are your body telling you the same thing, twice.

Why perimenopause turns up the volume

If this pattern showed up or got worse in your 40s, you’re not imagining it.

The Swiss Perimenopause Study followed 127 women aged 40 to 56 through the transition. As estradiol and progesterone declined, cortisol went up.

Progesterone is part of the why. It has a naturally calming effect on the brain, and it’s often the first hormone to slip in perimenopause, sometimes years before your periods change. Less progesterone means less of that built-in brake on your stress response. The same stressors you used to handle without blinking can now set off a bigger cortisol response, and it takes longer to settle back down.

So perimenopause doesn’t create the flattened curve on its own. It takes whatever stress your body was already carrying and turns up the volume.

Why your labs keep coming back normal

If you’ve ever asked your doctor about cortisol, you probably got one blood draw, first thing in the morning. And it probably came back normal.

There are a few reasons that test can miss what you’re living.

It’s one moment. A single morning blood draw tells you where your cortisol was at 8am on one day. It can’t tell you whether it crashed at 2pm or stayed high at 10pm. And the pattern is the whole story.

It’s built to catch disease. Standard cortisol testing is mostly used to rule out rare conditions where the adrenal glands make far too much or far too little cortisol. The normal range is wide for that reason. A woman can be well inside it and still feel wired at night and dragging all day.

It measures total cortisol. Most of the cortisol in your blood is bound to a carrier protein and isn’t active. If you take oral estrogen or birth control, your blood cortisol can even read higher, simply because estrogen raises the level of that carrier protein.

None of this means your doctor did anything wrong. It means the test was answering a different question than the one you were asking.

The pearl: A single blood draw is a snapshot. Your cortisol rhythm is more like a movie.

How to actually get data

You don’t have to guess. There are tests that look at the rhythm instead of a single moment, and at the minerals your stress response runs on. These are the three I use with clients.

Salivary cortisol. I use Genova’s Adrenocortex Stress Profile. You collect four saliva samples at home on one day: morning, around noon, late afternoon, and late at night. It also measures DHEA, another adrenal hormone, in the morning sample, and there’s an option to add two extra samples right after waking to capture your morning cortisol surge. Saliva measures the free, active cortisol, and those four samples line up almost exactly with the two problem times: late afternoon and late night. It’s a well-established method. Late-night salivary cortisol is even one of the Endocrine Society’s recommended screening tests for serious cortisol disorders.

DUTCH testing. This one uses dried urine samples collected across a day. Along with your cortisol pattern, it shows how your body is breaking down cortisol and your sex hormones. I reach for it when a woman’s stress symptoms are tangled up with hormone symptoms and I want to see both at once.

HTMA. A hair tissue mineral analysis measures the minerals stored in a small sample of your hair over the past few months. It shows how your body has been handling stress at the tissue level, through minerals like magnesium, sodium, potassium, and calcium. It’s by far the most affordable of the three, and it’s the baseline I include in my programs, because minerals are the foundation everything else runs on. I think of it as a lifestyle screening tool, not a diagnostic test.

Each one answers a different question. None of them replaces bloodwork. Together, they turn “I just feel off” into something you can actually see.

Below, for paid subscribers: real results from three women using a DUTCH hormone test, a saliva cortisol test, and an HTMA (shared with permission, all identifying details removed), how to collect a saliva test so your results are actually accurate, the honest truth about hair testing that most practitioners won’t tell you, which test I’d start with for your symptoms, and a simple plan to get your rhythm through this clock-change week.

Read more

For most of my life, my answer to pain was to push through it. I was the type A overachiever that could not accept anything less than “all in.” I grew up as an athlete and prided myself in the “no pain, no gain” mentality.

Over the years, I’ve had carpal tunnel syndrome, plantar fasciitis twice, and patellofemoral syndrome, that nagging pain around the kneecap. Every time, I did what high-achieving women do. I kept going. I modified a little, rested a little, and showed up anyway. I iced, did stretching exercises, used infrared, and took the curcumin for pain relief. And, got back up the next day and did it all over again.

Last year, my joints hurt so badly that some days just getting moving felt like work. And I was still going to Orange Theory. I loved Orange Theory as it lit me up. It was my mental therapy. I told myself the movement would help. In fact, it made everything worse.

What I finally understood is this: the pain was my body talking to me. Every time I white-knuckled through it, I overrode that message. And when you keep overriding your body’s communication, it doesn’t go quiet. It actually gets louder and more painful.

I see the same pattern in almost every woman who comes to me. She’s eating clean, taking her supplements, working out, and running her family and her career at full speed. She’s doing everything right on paper. And her body still won’t cooperate. It has become unruly like a rebellious child that can’t be tamed.

Usually, nothing is broken. Her body simply doesn’t feel safe. And a body that doesn’t feel safe won’t put its energy into healing.

Your body runs on a priority list

Your body was designed with one job above all others: keep you alive.

When your brain senses a threat, it reorganizes everything around that job. Blood sugar goes up so you have fuel to run. Digestion slows down. Repair gets put off. And reproduction, the thing your hormones are built around, goes to the very bottom of the list.

That isn’t a theory I made up. Doctors see it clearly in a condition called functional hypothalamic amenorrhea, where a woman’s periods stop with no disease behind it. I see this in many athletes. The Endocrine Society’s guideline says it’s usually driven by stress, weight loss, too much exercise, or some combination of the three. It doesn’t only happen to very thin women, either. It can happen to a normal-weight woman who is simply under too much stress.

The word “functional” matters here. It means nothing is actually broken. When the causes are corrected, ovulation comes back online.

In other words, when your body decides it isn’t safe, it would rather protect you than make a baby or keep your weight optimal. That’s not your body failing you. That’s your body doing exactly what it was designed to do.

And you don’t need to lose your period for this to be happening to you. The same priority list runs quietly in the background of every woman who’s been running on empty for years.

The pearl: Your body can’t prioritize hormone balance while it still thinks it’s under threat.

The rhythm that’s supposed to carry you

Cortisol gets a bad reputation, but you need it. It’s the hormone that gets you out of bed.

In a healthy rhythm, cortisol rises in the morning so you wake up with energy. Then it tapers off through the day, reaching its lowest point at night so you can wind down and fall asleep. High when you need to go. Low when you need to rest.

When a woman has been running on stress for years, that curve flattens. Her cortisol is too low in the morning, when she needs it, and too high at night, when she needs it to be quiet. So she drags herself out of bed, survives on coffee until lunch, hits a wall at 2pm, and then lies awake at 10pm with her brain running a marathon.

Wired at night. Dragging all day. If that’s your life right now, you’re in the right place.

That flattened curve matters for more than how tired you feel. A 2017 analysis that pooled the research on daily cortisol rhythms found that flatter curves were linked to poorer health in 10 of 12 categories they looked at. The strongest link was with the immune system and inflammation. As the lead researcher put it, we want cortisol high when it’s supposed to be high and low when it’s supposed to be low.

You may have heard this called adrenal fatigue. I don’t love that term. Your adrenal glands aren’t worn out. The rhythm that tells them when to work has been knocked off course, and rhythms can be retrained.

The pearl: Your energy problem is often a timing problem.

Five ways we tell our bodies we’re not safe

Most of the women I work with aren’t in obvious danger. But the body doesn’t sort stress into “real” and “not real.” It reads signals. And many of the habits we’re praised for send the exact signal that something is wrong. Your body is not good at deciphering stress. Stress is stress. If you have relationship issues or a work stressor that is weighing on you, it might as well be a Bengal Tiger coming after you for lunch. Here are some examples of stressors that add up:

1. Eating too little, or going too long without food. Skipped breakfasts, a salad for lunch, and long fasting windows tell your body food is scarce. That’s one of the main drivers behind the shutdown I described above. I’m a fan of a 12 to 14 hour overnight window. Much beyond that, many women in midlife start paying for it.

2. Blood sugar crashes. Every time your blood sugar drops too low, your body calls in cortisol to bring it back up. If you read my insulin resistance article, this is where the two connect. A day of crashes is a day of small emergencies.

3. Short sleep. In one controlled study, cutting sleep short raised evening cortisol by 30%, and the free, active form of cortisol jumped by 200%. The normal drop in cortisol across the day was dampened by 21%. The participants were also hungrier, and the more their cortisol rose, the hungrier they got.

4. Training through pain. This was me, unfortunately. Exercise is good for you, but your body can read it as stress too. The Endocrine Society names too much exercise as one of the drivers of that hormonal shutdown. When you’re already depleted, one more hard workout isn’t building you up. It’s pulling from an account that’s already overdrawn.

5. Running out of minerals. Stress burns through magnesium. A 2020 review describes it as a vicious circle: stress increases magnesium loss, and low magnesium makes your body more reactive to stress. Sodium and potassium matter here too, because your adrenal glands and nervous system depend on them to stay steady.

None of these are character flaws. They’re signals. And every one of them can be changed.

The pearl: Rest, food, and sleep aren’t rewards you earn. They’re the signals that tell your body it’s safe to heal.

Why nothing sticks until this is fixed

This is why so many women tell me they’ve tried everything.

The new supplement helped for two weeks. The diet worked until it didn’t. The workout plan left them more tired than when they started. Even hormones, as I wrote in my last series, can only do so much when the foundation underneath them is crumbling.

If your body believes it’s in danger, it will keep spending its resources on survival. You can add the best protocol in the world on top of that, and your body will keep doing what it was designed to do: protect you first.

That’s why Safety is the first pillar of everything I do with clients. Before we talk about Stability, Strength, or Synchronicity, your body has to know it can pause and simply breathe.

I believe our bodies were built with a kind of innate wisdom in them. Even when you’re exhausted and out of balance, your body hasn’t stopped trying to take care of you. It just believes the emergency never ended. Healing starts when you stop fighting your body and start giving it what it’s asking for.

And that’s stewardship, not selfishness.

The pearl: You can’t push your way out of a stress pattern. You have to show your body it’s safe to come out of it.

Below, for paid subscribers: what I look for on a standard blood panel that most doctors skim past, how a simple hair test shows your stress pattern, and the exact one-week reset I give my own clients, including the drink I have almost every woman start on day one.

Read more

Download your guidebook below. 👇

Big hug,
Mandy

Root Cause Files Month 2 Wired At Night (1)

10.8KB ∙ PDF file

Download

Download

Read more

I’ve spent four articles walking you through hormones. The FDA’s reversal. Bioidentical versus conventional. Insulin resistance. Muscle and bone.

So this might surprise you: I don’t take hormones currently.

I’m 46, and I feel great. I’ve used progesterone cream, and that’s it. I tried oral progesterone for a month and it ended up messing with my period. I decided to go back to the cream. I like it because it has been effective for me and it is not invasive.

I’m not against hormone therapy. In fact, I have advanced training in bioidentical hormone replacement with A4M and Worldlink Medical. I did this training becaue I wanted to know the truth not only for myself, but the thousands of women I have worked with over the years. For some women, it’s exactly the right tool at a particular time in their life. But foundations matter, period. Mineral and nutrient deficiencies, toxins, stress, and poor sleep all create a mismatch underneath your symptoms. In my experience, some women do okay on hormones for a while. But if the foundation underneath is off, hormone therapy won’t get them across the finish line.

So in this final part of the series, I’m taking on the two fears that keep so many women from even considering hormones: their heart and cancer. I’ll show you what the strongest research actually says. Then I’ll tell you how I’d decide.

The pearl: Hormones are a tool, not a requirement.

What the study that scared everyone actually found

In 2002, the Women’s Health Initiative, known as the WHI, made headlines that scared a generation of women away from hormones.

Two details rarely made those headlines. The women averaged 63 years old, more than a decade past the typical age of menopause. And the hormones weren’t bioidentical. Women took conjugated equine estrogens, sold as Premarin and made from pregnant horses’ urine, and many also took medroxyprogesterone acetate, a synthetic progestin.

Two gynecologists made this point bluntly in 2024, writing in Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists. The WHI enrolled older women who mostly didn’t have symptoms, yet for more than two decades its results were applied to every estrogen product, every woman, and every delivery method. When the early results were announced in 2002, prescriptions fell 79%, and the benefits the trial did find, fewer fractures and less colon cancer. This information wasn’t part of that announcement. They compare hormones to blood pressure medications: nobody assumes those are all interchangeable, and honestly, hormones shouldn’t be treated that way either.

Then researchers kept following those women. After 18 years and more than 27,000 women, hormone therapy did not change the risk of dying from any cause, from heart disease, or from cancer. During the years they took hormones, women in their 50s actually had a lower risk of dying from any cause. Over the full 18 years, that difference faded.

In November 2025, the FDA removed most of the boxed warning on hormone therapy, and its labeling now points to starting within 10 years of menopause or before age 60. I covered that reversal in the first article of this series and you can go back and check that out here.

I want to be clear about my stance here as my Master’s degree was in research. When it comes to safety, I give the most weight to large randomized controlled trials, where women are assigned to hormones or placebo by chance. This is gold standard research and is the best evidence to form hypotheses and conclusions from. Observational studies, on the other hand, look back at women who chose hormones and can’t prove cause and effect. So in every section below, I’ll tell you which kind of evidence you’re looking at, and which kind of hormone it tested.

Three things the headlines get wrong

Most of the fear around hormones comes from headlines and social media posts built for clicks. They report the scariest numbers or worst case scenarios with none of the context. And underneath most of that fear is one big mix-up: the hormone replacement traditionally given to women in the United States is not the same thing as bioidentical hormone replacement, meaning estradiol, progesterone, and testosterone that match what your body makes. Three distinctions sort it out.

1. Premarin is not estradiol. Premarin is a blend of estrogens from pregnant horses’ urine. Estradiol is the same estrogen your ovaries make. In the research we’ll walk through, they don’t behave the same way, especially when it comes to clots.

2. Provera is not progesterone. Provera is medroxyprogesterone acetate, a synthetic progestin. Micronized progesterone is identical to the progesterone your body makes. The breast cancer signal in the WHI came from the combination with Provera.

Why does that matter? Synthetic progestins like Provera are built by chemically altering the structure of a natural hormone. That makes them work well as a pill and lets a company patent them. But even a small change in structure can change how a hormone acts in your body, which is part of why Provera doesn’t behave like progesterone. Bioidentical estradiol and progesterone have the exact structure your body makes. Because they occur naturally, the hormones themselves can’t be patented, only a specific product or delivery method can. That’s likely one reason the bioidentical options got far less marketing, and far less research funding, for decades.

3. HRT is not ERT. Estrogen replacement therapy, or ERT, means estrogen alone, used by women who’ve had a hysterectomy. Hormone replacement therapy, or HRT, usually means estrogen plus a progestogen. In the WHI, they went in opposite directions on breast cancer. Estrogen alone lowered it. Estrogen plus Provera raised it. A headline that lumps them together is telling you half the story.

So the next time you see a scary hormone headline, ask three questions: Which estrogen? Which progestogen? And how old were the women when they started?

The pearl: “Hormones” isn’t one thing. Which ones, how, and when change everything.

Your heart: timing is everything

When researchers pooled the randomized trials, a pattern showed up. Women who started hormones before 60, or within 10 years of menopause, had a lower risk of heart disease and of dying from any cause than women on placebo. Women who started later saw no benefit. Most of those trials used conventional hormones, like the WHI.

One randomized trial measured real outcomes in recently menopausal women. In the Danish Osteoporosis Prevention Study, 1,006 healthy women aged 45 to 58 were assigned to hormones or no treatment. They took estradiol, and women with a uterus also took a synthetic progestin. After 10 years, the women on hormones had a significantly lower combined risk of death, heart failure, and heart attack: 33 events compared with 53 in the women who took nothing. There was no apparent increase in cancer, clots, or stroke. It has its limits. The women knew which group they were in, there was no placebo, and the event numbers were small enough that death, heart failure, and heart attack weren’t significant on their own. But it’s one of the few randomized trials to measure actual heart events in women who started early, and the direction is clear.

One randomized trial was built specifically to test that timing. In ELITE, 643 women took bioidentical oral estradiol or placebo, and women with a uterus also took micronized progesterone. When estradiol started within 6 years of menopause, it slowed the thickening of the carotid artery walls. When it started 10 or more years after menopause, it had no effect.

Smaller studies help explain why. In a randomized study of 27 women, oral estradiol improved how well blood vessels relaxed and lowered LDL cholesterol and Lp(a) within weeks.

The type of progestogen matters for your heart, too. In PEPI, a three-year randomized trial of 875 women aged 45 to 64, estrogen or estradiol raised HDL, the protective cholesterol. Adding micronized progesterone kept most of that benefit. Adding the synthetic progestin, medroxyprogesterone acetate, blunted it. For women with a uterus, the combination with micronized progesterone had the most favorable effect on HDL.

One guardrail matters here. Even the researchers behind this work caution that it isn’t a reason to start estrogen to prevent heart disease. It’s a reason a woman with real symptoms shouldn’t be denied hormones out of fear for her heart.

The pearl: When you start matters as much as what you take.

Cancer: the type of progestogen matters

This is the fear I hear most, so let’s start with the randomized evidence.

The WHI ran two separate trials. Women who had a hysterectomy took estrogen alone. Women with a uterus took estrogen plus the synthetic progestin. The results went in opposite directions. Women on estrogen alone were 23% less likely to be diagnosed with breast cancer and 44% less likely to die from it than women on placebo. Women on estrogen plus the synthetic progestin were about 20% more likely to be diagnosed.

Relative numbers like “20% more likely” sound scarier than they are, so here are the absolute ones. In the WHI, women on estrogen plus the synthetic progestin had about 41 invasive breast cancers per 10,000 women each year, compared with 33 on placebo. That’s about 8 extra cases per 10,000 women per year. Breast cancer deaths were 2.6 versus 1.3 per 10,000 women per year. The North American Menopause Society, now called The Menopause Society, put it in perspective: the added risk from five years of that combination was similar to the added risk of reaching menopause five years later with your own hormones.

So the progestin, not the estrogen, looks like it is the problem. And, observational research agrees. In a French study that followed more than 54,000 women, hormone therapy with synthetic progestins was linked to higher breast cancer risk. Hormone therapy with micronized progesterone, the bioidentical form, was not.

The pattern showed up before the WHI, too. A 2000 study in the Journal of the National Cancer Institute compared women with breast cancer to women without it. Estrogen plus a synthetic progestin was linked to about a 24% higher breast cancer risk for every 5 years of use. Estrogen alone was linked to about 6%, which wasn’t statistically significant. It was observational, but it pointed at the progestin two years before the WHI confirmed it in a randomized trial.

Dr. Neal Rouzier, my mentor and teacher, put it bluntly: Provera causes the problem, not bioidentical progesterone. I challenge you to find a study where progesterone causes cancer. Here’s what the evidence actually supports. Provera, the synthetic progestin, has randomized trial evidence of harm from the WHI. Micronized progesterone doesn’t. A 2018 systematic review by an international expert panel found that estrogen combined with micronized progesterone didn’t raise breast cancer risk for up to 5 years of use, with limited evidence of a small increase after 5 years. So the type of progestogen matters enormously, and so does how long you take it.

Finland adds another piece for consideration. Finnish women mostly use estradiol, often paired with a synthetic progestin called norethisterone acetate. In a nationwide registry study of more than 221,000 women on estradiol plus a progestogen, breast cancer risk after 5 or more years of use was about double with norethisterone acetate, and about 64% higher with medroxyprogesterone acetate. Norethisterone is unusual: the body partly converts it into ethinyl estradiol, the synthetic estrogen used in birth control pills. That’s observational data, but it’s exactly why Dr. Rouzier asks the question every woman should be asking that is concerned about their health long-term: why use a synthetic progestin at all when bioidentical progesterone is available?

There’s also an older clue about the body’s own progesterone. In a 1981 Johns Hopkins study of 1,083 women evaluated for infertility, women with progesterone deficiency had about 5.4 times the risk of breast cancer before menopause. It was small and observational, and the risk didn’t show up after menopause, but it fits the idea that progesterone is protective rather than harmful.

In fairness, not every study agrees and there are many confounding variables to consider. A 2019 analysis that pooled 58 observational studies found higher breast cancer risk with both estrogen plus a progestogen and estrogen alone, with the combination carrying the larger increase. That’s observational data too, and it runs against what the randomized trial showed for estrogen alone. When good studies disagree, simple explanations like ‘hormones cause cancer’ or ‘hormones are completely safe’ don’t hold up. The finer details matter. We need to keep asking questions.

Breast cancer gets all the headlines, but ovarian cancer belongs in this conversation too. A nationwide Finnish study followed more than 224,000 women taking estradiol plus a synthetic progestin. With less than 5 years of use, their ovarian cancer risk wasn’t raised. After 5 years, it rose about 21%, mainly for serous ovarian cancer, the most common type. And unlike clots, the route didn’t change it: oral and transdermal looked the same. Ovarian cancer is rare, so a 21% relative increase is a small change in absolute risk, but it’s a reason how long you take hormones belongs in the conversation. This was an observational study, and it didn’t include micronized progesterone, so we don’t know whether that would look different.

One more rule that shouldn’t bend: if you have a uterus, estrogen needs progesterone alongside it. Estrogen on its own raises the risk of endometrial cancer, and that’s the one boxed warning the FDA kept.

You can see progesterone’s protective role in women who don’t ovulate regularly, including many with PCOS. Without regular ovulation, they make little progesterone, and meta-analyses show they carry a significantly higher risk of endometrial cancer. Their breast cancer risk, interestingly, isn’t significantly higher overall.

The pearl: Which hormone you take matters as much as whether you take one.

Clots: the route matters most

The randomized evidence first. In the WHI, oral hormones raised the risk of blood clots and stroke. The estrogen-alone trial was stopped early because of stroke risk. Remember, that was oral Premarin, not bioidentical estrogen or estradiol, in women averaging 63.

For the bioidentical questions, we have to lean on observational data, so read this section with that caveat in mind.

A large 2019 study of UK medical records compared hormone types. Oral Premarin was linked to about a 49% higher clot risk. Oral estradiol, the bioidentical form, was linked to about 27% higher risk. Transdermal estradiol, mostly patches, showed no increase at all. A smaller US study found the same pattern between pills, with Premarin carrying about twice the clot risk of oral estradiol. A companion study of 140 women from the same health system found that Premarin users’ blood was measurably more prone to clotting than estradiol users’ blood.

The absolute numbers help keep this in perspective. Oral hormone therapy overall worked out to about 9 extra clots for every 10,000 women taking it. Real, but small and a consideration when weighing the pros and cons.

The reason comes down to your bioindividualty and your liver. Oral estrogen passes through the liver first, at four to five times the concentration in the rest of your bloodstream. That first pass improves cholesterol, which is why small studies show oral estradiol raising HDL and improving how blood vessels relax. But the same pass also raises clotting factors and inflammatory proteins like C-reactive protein. Transdermal estrogen skips the liver, so it skips both the cholesterol boost and the clotting effect.

That’s a real trade-off, and it’s why route should match the woman. A clotting history points one direction. A stubborn cholesterol picture might point another.

A 2025 systematic review looked specifically at women who already carry clot risk factors, like a past clot, obesity, or an inherited clotting disorder. Across 10 studies, transdermal estrogen showed no increased clot risk. Oral estrogen alone came next, and oral estrogen plus a progestogen carried the highest risk. Most of those studies were observational, and the authors called for more current data, but the direction matches everything above.

Stroke follows a similar pattern. In a large UK study of more than 15,000 women who had a stroke, compared with matched women who hadn’t, oral hormones were linked to about a 28% higher stroke risk. Low-dose estradiol patches, 50 micrograms or less, showed no increase. Higher-dose patches did. That’s observational too, but it points the same direction: transdermal at the lowest dose that works is the gentlest option for clot and stroke risk.

Oral estradiol has its own benefits and I want to convey that here as well. In the randomized EPAT trial of 222 healthy postmenopausal women, carotid artery walls actually got slightly thinner over two years on oral estradiol, while they kept thickening on placebo. The ELITE trial later confirmed the benefit when estradiol starts within six years of menopause. These trials measured early artery wall changes in healthy women, not reversal of established heart disease, and they weren’t designed to measure strokes. But they’re a reminder that route is a trade-off rather than a simple right or wrong.

The pearl: The type of estrogen matters, the type of progestogen matters, and the route matters most.

The gap nobody talks about

Here’s what I want every woman to know, whichever way she is leaning on what is best for her.

No large randomized trial has tested bioidentical estradiol plus micronized progesterone on heart attacks, strokes, clots, or breast cancer. This is frustrating when we are trying to determine what is the best path forward for us from a health optimization standpoint.

ELITE and the small route studies did use bioidentical estradiol, but they measured artery thickness, cholesterol, and blood vessel function, not actual heart attacks or cancers. The reassuring findings on micronized progesterone and transdermal estradiol come mostly from observational studies. And it helps to know where that research comes from: much of it was done in Europe, where estradiol and micronized progesterone have long been the standard choices, while American research focused for decades on Premarin and Provera.

Put it all together, and you have strong randomized data on timing, smaller randomized studies on bioidentical hormones, and consistent observational patterns from across Europe. That adds up to a reasonable case. It’s not the final word, though, and anyone who tells you the science is settled in either direction is overselling it.

Dr. Rouzier often points to 30 years of research supporting the safety of bioidentical hormones, and that body of evidence is large and remarkably consistent. Most of it is observational, though, which is why I still name the gap.

That’s exactly why this has to be a personal decision.

There’s a line often credited to Mark Twain, though it likely traces back to the 19th-century humorist Josh Billings: “It ain’t so much the things we don’t know that get us into trouble. It’s the things we know that just ain’t so.”

That’s the lesson of this whole series for me. Hold what you know loosely, and keep challenging it. I’ve changed my own mind more than once, and I expect I will again. We’re all still learning.

It also comes back to radical responsibility. Nobody will advocate for your body the way you will. Keep researching. When you see a statistic, ask whether it’s a relative risk or an absolute one. And insist on real informed consent, the kind where you understand the benefits, the risks, and the alternatives before you decide. Most women have never been given that.

The pearl: Hold what you know loosely, and keep asking better questions.

How I’d decide: three questions

1. How do you feel?

Hot flashes, sleep, mood, brain fog, joint pain, and how much they’re disrupting your life. Symptoms lead this decision.

2. What does your bloodwork say?

In perimenopause, your hormones don’t decline in a straight line. They swing, sometimes from one week to the next. A single estradiol or FSH test can look normal on a hard day or alarming on a good one. That’s why I never make a hormone decision off one number. Your symptoms lead. Your hormone labs add context. And the rest of your bloodwork shows how your foundation is holding up underneath it all.

That broader bloodwork is far more stable, and it tells you a lot about how you’re aging:

• A complete blood count with differential

• A comprehensive metabolic panel

• A full thyroid panel, since thyroid problems can look a lot like perimenopause

• An iron panel, since heavy periods can quietly drain your iron

• Inflammatory markers like homocysteine and hs-CRP, both tied to heart health

• Vitamin D, ideally both the storage form and the active form

3. How solid is your foundation?

If you’re under-fed, under-slept, stressed, depleted in minerals, or insulin resistant, start there. Rebuild it, then reassess how you feel. If your foundation is dialed in and your symptoms are still disrupting your life, hormones become a very reasonable tool.

Sleep belongs on that list for more than energy. Night shift work, which disrupts the body clock, is classified by the World Health Organization’s cancer research agency as a probable carcinogen, and studies have linked long-term night work to a modestly higher breast cancer risk. One leading explanation is melatonin, a hormone with cancer-protective properties. In a study of 261 women working at a hospital, those on rotating night shifts produced less melatonin at its peak, and more years of shift work were tied to lower levels. It’s observational, and the link is still being studied, but it’s one more reason sleep is part of the foundation I protect first.

Body composition belongs there too. After menopause, fat tissue becomes a main source of estrogen, which is one reason excess body fat is an established risk factor for postmenopausal breast cancer. In a WHI study of more than 61,000 postmenopausal women, those who lost at least 5% of their body weight over three years had about a 12% lower breast cancer risk over the next decade than women whose weight stayed stable, whether or not they meant to lose it. Weight gain didn’t change overall risk, but it was tied to a 54% higher risk of triple-negative breast cancer, one of the more aggressive types. This was observational, so it shows a link, not proof. If you read my last article, you know I don’t want you chasing a smaller number on the scale. This is a reason to lose fat the right way: by building muscle, eating enough, and protecting your bones while the fat comes off.

Two more foundation levers have some of the strongest evidence in all of breast cancer research. A major review by the American Institute for Cancer Research and the World Cancer Research Fund pooled 119 studies covering 12 million women. After menopause, about 10 grams of alcohol a day, less than one standard drink, was linked to a 9% higher breast cancer risk. Vigorous exercise was linked to a 10% lower risk, and even moderate activity like walking and gardening was linked to a 13% lower risk. The researchers estimated that about one in three breast cancer cases in the US could be prevented if women didn’t drink, stayed active, and maintained a healthy weight. None of that requires a prescription.

There’s one more link I want you to know about, because it ties this whole series together. In a WHI study of postmenopausal women without diabetes, women not taking hormones who had the highest fasting insulin levels had about 2.4 times the breast cancer risk of women with the lowest levels, even after accounting for their estrogen levels. The researchers concluded that high insulin may be an independent risk factor for breast cancer, and may help explain why excess body fat raises risk after menopause.

Dr. Rouzier’s view is that losing estrogen drives insulin resistance, and insulin resistance helps drive breast cancer after menopause. The research clearly supports the insulin piece. It’s one more reason fasting insulin, from the insulin resistance article, belongs on your lab list. Being metabolically fit won’t erase every risk factor, since age, genetics, and family history still count. But it shifts more of the odds in your favor than most women realize.

The pearl: Hormones can support a strong foundation. They can’t replace one.

When hormones make sense

I don’t take hormones, but I want to be just as clear about when they can be the right call:

• Symptoms that are disrupting your life even after you’ve done the foundational work: hot flashes that wreck your sleep, mood changes you don’t recognize, nights you can’t get back.

• Early menopause, when your body loses its hormones years ahead of schedule.

• High fracture risk. In the bone study I shared last time, hormone therapy cut vertebral fractures by about 65%, more than any other option tested.

• Insulin resistance that won’t budge even after you’ve dialed in food, strength, sleep, and stress. Randomized trials show hormone therapy can improve insulin resistance in postmenopausal women, so it can be a reasonable next tool.

If that’s you, hormones may be exactly the right tool. Started within the window, with thoughtful choices about formulation and route, the research is far more reassuring than you were told. And your foundation still matters, because it decides how well your body uses them.

When to take extra care

Some women need a much more careful conversation before starting hormones, and some may not be good candidates at all:

• A personal history of breast cancer or another estrogen-sensitive cancer

• A past blood clot or stroke

• Active liver disease

• Unexplained vaginal bleeding, which needs to be evaluated first

For women with a history of blood clots, my training with Dr. Rouzier is clear: oral estradiol can be hard to justify. Transdermal estradiol is the safer choice, and it’s what the research supports, including in women who already carry clot risk factors.

Getting a provider to talk with you about hormones is the easy part. Knowing which labs to bring, how to read them, and which questions to ask is where most women get stuck. Below the paywall, I’m putting every lab from this series in one place with when to draw each one, the common heart marker that synthetic estrogen can push up and fool you, and the exact questions I’d ask a provider about formulation, route, and monitoring.

Read more

For the last three months, I have been all in on my body recomposition journey. After fighting musculoskeletal injuries over the last 3 years including patellofemoral pain syndrome and painful joint issues, I am so glad to be back in the gym lifting heavy again generally pain free. I have also been committed to ten to twelve thousand steps a day. Heavy weights four days a week. A small, intentional calorie deficit. Real meals, enough protein, and carbs at every single meal. I upped my carbs and my body is thanking me!

And the scale has barely moved. My past self would have been extremely discouraged and wanting to throw in the towel.

There was a time that would have sent me straight to rigidly cutting more food and adding more cardio. I used to think the scale told me whether it was working. I simply don’t believe that anymore.

What the scale isn’t showing you: I’ve lost about 15 inches all around.

In my last article, I shared how years of under-eating and carb restricting caught up with me in perimenopause. This one picks up right where that left off, with your muscles and your bones. My goal right now is simply building more muscle and protecting my bones as I move closer to 50. In perimenopause, chasing a smaller body or fewer pounds can cost you both muscle and bone and no conventional physician or provider is going to tell you this.

The scale weighs you. It doesn’t tell you what you’re made of.

Your scale weighs everything at once: muscle, fat, bone, water, and last night’s salty dinner. It can’t tell you which one changed.

BMI is worse. It’s your weight compared to your height, nothing more. A strong woman with real muscle and a soft woman with very little can share the same BMI and have completely different health trajectories.

Strength coach Holly Perkins, who has coached women for 30 years, made this point on Keri Glassman’s podcast just recently. She argues that many of the body fat categories we were taught grew out of BMI, and they don’t hold up. She also sees women build muscle and lose fat at the same time on their body scans. That’s body recomposition, and it’s exactly what I’m doing right now.

It’s also why the scale is so misleading in this season. When you’re adding muscle and losing fat at once, the number can sit still while your body changes underneath it.

The pearl: The scale weighs you. It doesn’t tell you what you’re actually made of and how much muscle and fat you have.

The half of this story you can’t feel

Muscle is half of this story. Bone is the other half, and it’s the half nobody feels.

The Study of Women’s Health Across the Nation, known as SWAN, was the first large study to track women’s bone density every year across the entire menopause transition. Bone loss sped up sharply in late perimenopause and kept that pace into the first years after menopause. The fastest window ran from about a year before the final period to about two years after it.

In those years, women lost about 1.8 to 2.3% of their spine bone density every year, and about 1.0 to 1.4% at the hip. Over five years, that adds up to an average drop of 7 to 10% at the spine.

You can’t feel any of it. No symptom tells you your bones are thinning. For many women, the first sign is a broken bone or a DEXA scan that looks less than stellar.

And fractures are not minor. One in two women over 50 will break a bone due to osteoporosis. A woman’s fracture risk equals her combined risk of breast, uterine, and ovarian cancer. Nearly a quarter of hip fracture patients 50 and older die within a year, and half never regain the function they had before.

The pearl: Your bones are changing fastest when you can feel it least.

Why chasing a smaller body can cost you bone

This is where the smaller-body chase gets risky.

In SWAN, the lightest women lost bone the fastest. Women in the heaviest third lost bone 33 to 55% more slowly than women in the lightest third.

The research on dieting points the same direction. Weight loss from cutting calories takes bone along with fat. Lifting weights while you diet helps, but it doesn’t fully protect you. In a 2025 trial, older adults who lost about 10% of their body weight lost hip bone whether or not they did resistance training. Most of this research was done in adults in their 60s, not perimenopausal women. But the message lines up with what I see: when the body is under-fed, bone pays a price.

This matters even more if you’re on a GLP-1 like semaglutide. This isn’t an attack on anyone using them. In the main semaglutide trial, about 40% of the weight people lost was lean mass, which includes muscle. Those trials weren’t built to protect it, and none of them was designed around a woman in perimenopause, whose muscle and bone are already under pressure. If you’re on one, strength training and enough protein aren’t optional. They’re how you make sure what you lose is fat.

This isn’t a reason to fear change. It’s a reason to change the goal.

That’s why I’m keeping my deficit small on purpose. I’m in a muscle-building phase, and I want what I lose to come from fat while I build muscle and protect bone.

If you read my last article on Insulin Resistance Starts Years Before Your Labs Notice, you know where I land: feed and nourish your body. Under-eating costs more than your blood sugar. It costs your bones too.

The pearl: A smaller body is no win if it costs you bone to get there.

Building muscle that sticks

Holly made a distinction on that podcast that I wish every woman knew.

There are two ways a muscle grows. The first is the firm, toned feeling after a barre, Pilates, or yoga class. It fades within a day or two, because it’s mostly fluid moving into the muscle.

The second is when the muscle fibers themselves grow bigger and stronger. That comes from progressive resistance training, and it sticks around. Skip a week of workouts and it’s still there.

Progressive means the weight goes up over time. Holly keeps sets at 12 reps or fewer, and she’s been moving toward 8 to 10, because fewer reps let you lift heavier. The weight should decide the reps. If you can do 15 easily, the weight is too light.

Her biggest shift for women is simple. Stop working out to burn calories, and start working out to build muscle. Move some of your cardio or class minutes into lifting.

That’s what I’ve done. I still walk 10,000 to 12,000 steps a day, and I still do Pilates and yoga. But, without fail, four days a week you will find me in the gym lifting heavy.

This is the Strength pillar of my 4S Method, and it matters for your bones too. Holly’s upcoming book, Muscle & Bone, is built on the idea that strength training may do as much for bone density as nutrition does.

The pearl: Burn calories and you get a workout. Build muscle and you keep what you’ve earned.

Measure what matters

If the scale can’t tell you whether it’s working, measure the right things.

A DEXA scan is the gold standard, but there’s a catch most women don’t know. The same machine runs two completely different scans.

• A bone density scan gives you T-scores at your hip and spine. This is the one your doctor orders.

• A body composition scan shows your body fat, your lean mass, and where your fat sits. You usually get this one at a separate facility, and many cities have storefronts that offer it.

Holly sees real body composition changes on DEXA at about four to five months. I’m at three. My scale sitting still is right on schedule.

If you’re tracking at home, use a body fat scale for the trend only. Weigh once a week, on the same day, first thing in the morning. Or skip the numbers entirely: take progress photos, or pick one pair of jeans and notice how they fit.

A bone density scan has its own limit. It shows you the net result of the last year or two. It can’t tell you whether you’re losing bone right now.

There’s an inexpensive urine test that can. It’s called NTX, and it’s one of the most useful bone tests most women have never heard of.

When your body breaks down old bone, it releases small fragments of collagen into your blood and urine. NTX measures those fragments. A higher number means bone is being broken down faster. A lower number means breakdown is under control.

That’s what makes it so different from a DEXA. A DEXA shows where your bones have been. NTX shows what they’re doing right now, and where they’re likely headed.

That matters most in perimenopause. Remember SWAN: bone loss speeds up fastest around your final period. A DEXA can look perfectly normal while breakdown is already picking up, and NTX can catch that shift before a scan does.

It also shows change quickly. If you start strength training, rebuild your nutrition, or begin hormone support, NTX can show whether it’s working in three to six months. A repeat DEXA usually needs a year or two to show a difference.

And it’s often around $30. Ask your provider to add it to your next lab order.

Ordering the NTX urine test is the easy part. It is knowing what to do with the result where most women get stuck. Below the paywall, I’m sharing the exact number I have been trained to aim for, the collection mistake that can throw your result off, the supplement that makes a DEXA look better than your bones really are, and the most common bone medication that doesn’t build new bone at all. Plus my full plan, from lifting days to calories.

Read more

In my last hormone article, I told you insulin resistance deserves a much closer look before hormones ever enter the conversation. I am going to repeat this. Hormones are not the villain. I want to start with my own body, because I learned this one the hard way.

Perimenopause did not arrive quietly or nicely for me once I hit 44. I was tired in a way sleep didn't fix. My joints ached. I ended up with a major knee injury from running. And then I started noticing chin hair. Not one stray hair. A lot of them. I have never had facial hair in my life, and I legit thought I was turning into the bearded lady from Spaceballs. Do you all remember that one???

I was doing what I believed was the disciplined, healthy thing. I had been low carb for years. I was intermittent fasting. And I simply wasn’t eating enough food to keep my blood sugar levels stable. My weight loss efforts were not working. And, it finally hit me that I needed to pivot.

Frankly, I used to think eating less and going longer between meals was the cleanest path to steady blood sugar. I used to think that carbs were a problem for women that were trying to balance blood sugar levels and lose weight, but I don’t believe that anymore. We have been lied to.

For me, what was sitting underneath all of it was insulin resistance.

My frustrating symptoms, energy issues, and bloodwork tipped me off to what was really going on below the surface.

So today we’re talking about what insulin resistance actually is, why perimenopause turns up the volume on it, and why the standard blood sugar test is usually the last one to know.

Insulin climbs first

Insulin is the hormone that walks sugar out of your bloodstream and into your cells, where it becomes energy. When your cells are primed and responsive, a little insulin does the job.

Insulin resistance is what happens when your cells stop answering the door. So your pancreas knocks louder. It makes more insulin, then more again, to move the same amount of sugar.

This is the part most women never hear. Insulin climbs first. For years, your pancreas compensates so well that your blood sugar stays right in the normal range. Your fasting glucose looks fine. Your hemoglobin A1c looks fine. Blood sugar is the last domino to fall.

The pearl: By the time your blood sugar looks high, your insulin has been working overtime for years.

Why perimenopause turns up the volume

Why perimenopause turns up the volume

Insulin resistance can happen to anyone. But women hit a turning point in midlife. Harvard Health reported this year that the risk climbs after 50. I’d push that timeline earlier. The pattern starts building in perimenopause, years before the numbers catch it.

As estrogen and progesterone fall, your body starts storing fat differently. More of it lands around your middle. That belly fat makes insulin resistance worse, and the higher insulin that follows tells your body to store even more fat in the same place. Harvard’s dietitian called it a vicious cycle.

That fat is also active tissue. It releases free fatty acids and inflammatory chemicals called cytokines into your bloodstream, and those push your cells further toward resistance. If you read Part 1, this is the inflammation thread showing up again.

Then add stress. Cortisol’s job is to raise blood sugar fast for an emergency. When the emergency never ends (the job, the kids, the aging parents, the list), cortisol keeps blood sugar up and your cells grow less responsive to insulin. This is why Safety is the first pillar of the 4S Method. A body that feels under threat holds on.

Sleep matters here too. Fewer than seven hours a night makes your body less responsive to insulin on its own.

This is where hormones come back into the conversation. A large analysis presented at the 2024 Menopause Society meeting pooled 17 randomized trials and more than 29,000 healthy postmenopausal women. Hormone therapy significantly reduced insulin resistance.

Hormones and insulin feed each other. Falling hormones make insulin resistance worse. And unaddressed insulin resistance means you’re giving hormones to a body that can’t fully use them.

I don’t believe God designed women to fall apart in midlife. I believe our bodies were built to move through seasons, and perimenopause is one of them. Hormones are meant to shift. A body too depleted to handle that shift was never part of the design.

Your ovaries will make less estrogen and progesterone as you move toward menopause. That part is design. But how hard the transition hits you depends on your foundation. Your adrenal glands, your fat tissue, and your liver all keep working with hormones after your ovaries slow down.

That’s why I work minerals first. Those systems, and your insulin signaling too, all run on minerals, vitamins, antioxidants, and phytonutrients. Magnesium is a cofactor in insulin signaling inside your cells. Zinc helps your pancreas store and release insulin. Low vitamin D has been linked with insulin resistance in research. And your hormones are built from the fats and cholesterol you eat, then put to work with help from vitamins and minerals.

A well-rounded diet is the foundation for all of it: protein, carbohydrates, healthy fats, colorful plants, and enough of each. Underfeed a woman in perimenopause, and even the best hormone plan is working from an empty pantry.

So before I ask whether a woman needs hormone replacement, I ask whether her body has what it needs. Sometimes rebuilding the foundation brings things back into balance. Sometimes she still needs hormone support, and it works better because the foundation is there.

The pearl: Your hormones were designed to change. Your body was designed to handle it, when it has what it needs.

How it shows up

Insulin resistance whispers long before it shouts. These are the signs I want you to take seriously:

• The crash an hour after lunch, or the 2pm wall no amount of coffee touches

• Waking up at 3am and unable to fall back asleep

• Belly weight that won’t move no matter what you change

• Brain fog, constant hunger, and a shorter fuse than you recognize as yourself

• Skin tags

• Blood pressure, cholesterol, or blood sugar creeping up while you’re told it’s still normal

And then there’s the chin hair. High insulin can push your ovaries to make more androgens, the hormones behind facial hair. Pair that with falling estrogen and the balance tips. For me, it was one of the clearest signs something had shifted. And, thank the dear Lord for electrolysis!

Heavier or irregular periods can be part of this too. A 2025 study in the journal Menopause found that high fasting insulin predicted abnormal uterine bleeding in premenopausal women. It’s early research, and it’s worth knowing about.

There’s also a trap that fools almost everyone. In the middle stages, insulin can run so high that your blood sugar crashes after meals. You feel shaky, irritable, and desperate for a snack. In that moment your blood sugar really is low. But those lows pull your average down, so your A1c comes back looking great.

Your thyroid can play the same trick. In one study, researchers followed 940 people with normal thyroid labs for three years. Those with higher free T3, still inside the normal range, were more likely to lose insulin sensitivity over time. They looked normal on paper, but underneath, things were shifting in the wrong direction.

As a clinician, I had to scratch my head at this one, because we generally read a higher free T3 as a good thing. Interestingly, the people with higher free T3 were also the ones with higher BMI, larger waists, faster heart rates, higher blood pressure, and more fatty liver. That’s a metabolic stress profile, not a thriving-thyroid profile, and it deserves a closer look to unpack all the variables behind it. The thyroid connection needs its own article, and I’ll come back to it.

Why your labs miss it, and what to ask for

This is not an attack on your doctor. The standard approach follows the guidelines. The American Diabetes Association recommends adults 35 and older be screened every three years, usually with an A1c.

The problem is what that test measures. A1c and fasting glucose both measure blood sugar. And, remember, blood sugar is the last domino. By the time either one is flagged, your insulin has often been compensating for years.

Fasting glucose has another weakness. It’s a single snapshot. A stressful drive to the lab, a rough night of sleep, or your normal morning cortisol rise can move it on the day of your draw.

A1c depends on your red blood cells. If your iron is low, which is common in women with heavy periods, your A1c can read falsely high. Between that and the crash trap, the number you’re relying on can be off in either direction.

The pearl: A normal A1c can mean your body is still winning the fight. It doesn’t mean there isn’t one.

At your next blood draw, ask for these three:

• Fasting insulin. This is the one I’d fight for. It shows how hard your pancreas is working.

• Fasting glucose, drawn at the same time. Together, the two let your provider calculate HOMA-IR, a simple score for insulin resistance.

• C-peptide, if it’s available. It’s released alongside insulin and stays in your blood longer, so it gives a steadier picture.

Keep your A1c too. Just read it in context.

You may already have clues on labs you’ve had done. Triglycerides creeping up, HDL drifting down, and blood pressure inching higher tend to travel with insulin resistance.

And you can check one thing tonight with a tape measure. Measure your natural waist and the widest part of your hips, then divide waist by hips. For women, a waist-to-hip ratio above 0.85 is linked to higher risk.

I don’t wait three years. I recheck labs every six months. I’d rather catch a trend while it’s small and easy to turn around than confirm a diagnosis after it has settled in. That’s what optimal, not just normal, looks like in practice.

The reference range on your lab report tells you when you’re sick. It doesn’t tell you where your body works best. The optimal blood sugar and insulin numbers I actually want to see are in my Lab-Literacy guide for paid subscribers.

Below, I'm sharing exactly what I changed: my daily numbers, the supplement that made the biggest difference, and why carbs mattered more than I ever expected.

Read more

A client asked me something on a deep dive call recently that I think about a lot. She pointed at her lab report and asked, “What does the H and the L next to some of these numbers even mean?” She’d been getting this same report for years at her annual visit, but she did not know how to read between the lines or connect the dots of what these lab numbers actually mean for her.

If you’ve read the piece I wrote about “Your Labs Are Normal Is Not the End of the Conversation,” you already know where I stand on ranges. This is the Part 2 I promised. This is not my philosophy, but the actual mechanics of how you can take this information and understand what this means for you. We are going to walk through your own lab report and understand what you’re looking at, line by line, the same way I do on a review call.

Let’s start with the letters. H means high, L means low, both relative to what’s called the reference range, the range printed on your lab report next to your result.

Here’s the difference between a reference range and an optimal range, and I want to be precise about it because it changes how you actually look at your labs. It is important to understand that a reference range is built on a bell-shaped curve, a statistical analysis run across a large population, most of whom were never screened for whether they actually feel good. That range is designed to simply catch overt disease and the aim is to keep you alive. “Normal” was not designed for optimization and actually feeling vibrant and well in your body. So technically, you don’t want to be “normal.” Normal just means you match the statistical middle of a group that includes plenty of exhausted, depleted, inflamed people. And, lets be honest. That is the state of most Americans. Optimal is a different question entirely and this is what root cause medicine is actually built around: not just staying alive, but aging well, feeling vibrant in your body, and living a life free of dis-ease and dysfunction.

Here’s the second thing I want you to understand, because it changes how you’ll read every panel you ever get handed again. I rarely make an assumption off one marker sitting by itself. I look for patterns. If your uric acid runs high while your BUN runs low, that tells me something different than either number would tell me alone. In this case, these lab markers would prompt me to look more closely at your stomach acid and digestion before I ever look anywhere else. It is important to remember that a single number is a data point. A pattern across several numbers tells us a story and gives us deeper insight into what may be going on below the surface.

This is also why I don’t panic over one blood draw on one Tuesday morning. Blood work is a snapshot. Your body is always working to hold a tight, narrow window, because staying alive matters more to it than anything else. God designed the body has deep wisdom and intelligence. A single panel gives me some information on what was going on that particular day, but it doesn’t give me much else than that. This is why labwork over time can shed light on patterns across time. And, this is why I like to do other testing in my practice beyond just lab work. Hair Tissue Mineral Analysis (HTMA) is a non-invasive screening test that looks at stress resilience over time and measures the levels of essential nutrient minerals and toxic heavy metals that have accumulated in the hair shaft over a period of roughly three months. This test is helpful in looking at how the body is responding to stressors over time and how the body’s systems are responding to the enviornment it is living in. And, this is just about the house situation. This goes much deeper and is looking at the dynamic interplay between one’s nutrition, level of fitness, sleep, job situation, relationships, toxin exposure, past traumas to name some of the major ones. So, in a nutshell, it is a stress screening tool. I will dive into the benefits of HTMA testing and how it can give you a deeper look into the body systems in upcoming articles.

In this publication today, I have spent some time outlining optimal bloodwork lab ranges and the exact optimal numbers I use in my own practice as I believe that all women should have access to this information. I go through the lab panel marker by marker, and we go beyond the reference range your lab prints out on your lab report. That includes the standard panel your doctor might run, and I also dive into the deeper mineral markers that almost no conventional panel even touches.

Here’s what you’ll actually walk away knowing how to read: your

• CBC with Differential

• Blood sugar

• Thyroid

• Iron and minerals

• Vitamin D

• Lipid panel

• Inflammatory markers

• Kidney and detox markers

• Adrenal and electrolyte markers

• Protein and liver markers.

Ten sections, marker by marker, so the next time you get your bloodwork completed, you can actually understand what you’re looking at instead of just seeing a page of numbers with H’s and L’s next to them.

Everything below this point is for paid subscribers. I wanted the very first thing a paid subscriber gets from me to be genuinely useful, not a teaser. It is the full breakdown, ready to use on your very next lab report.

Read more

I’m pausing our walk through HRT and BHRT this week, not because there’s nothing left to say. There is plenty more coming, but because a recent woman from my own practice forced me to pause and reflect what is really going on in healthcare. It’s not really a departure from what we’ve been talking about, but just gives more context on what an astute, root cause practitioner should be doing. It is the same approach I go back to when considering a holistic plan for a woman that is struggling to find the help that she deserves.

A few weeks ago, I pulled up Leah’s thyroid panel on our first deep dive call. She is a new client that is “sick and tired” of feeling “sick and tired.” Her TSH was 5.18. Her doctor had already told her it was fine because “acceptable” conventional reference ranges can go as high as 6. It maddens me that we reduce a woman’s function down to levels that should fit in a box and dismiss her cries for help. So, my optimal functional ranges that are necessary for vibrant health land between 1.0 to 2.0 uIU/mL.

To give you a little more context, Leah has been living with debilitating fatigue, her hair is falling out in the shower, unexplained joint pain, libido in the tank, and thirty extra pounds that won’t move regardless of doing “all the things.” This has been going on for over 5 years (yep, you read that right), and every time she brought it up at her annual visit, she got the same standard answer: “your labs look fine.” Period. End of story. She was exhausted by not feeling heard and the incessant gaslighting. She was resigning herself to, is this the way it is going to be for the rest of my life. She is 45 years old, but feels like she is living in an 80 year old’s body. Yeah, but this is all “normal?”

I want you to hear this as I don’t beat around the bush. Normal and fine are not the same word, even though we’ve been trained to use them like they are.

Once you hit a wall and you can’t take your life anymore, that is when you will promptly get slapped with a subclinical thyroid diagnosis and will be put on Synthroid or Levothyroxine for the rest of your life. Most of these prescribers are not even looking at a full thyroid panel that dives into the deep end of the pool with the sufficiency and conversion of active thyroid. Have they looked at free T3 (active thyroid), free T4 (inactive thyroid), reverse T3 (body’s storage for inactive thyroid), or antibodies that are a sign of autoimmunity that is simmering below the surface? Most likely, no. So, if you happen to be the lucky patient that gets diagnosed with subclinical hypothyroidism, you will get handed a script for thyroid medication to fix the problem. Ironically, many women do not get told that there is no silver bullet or magical pill. It is all or nothing and no one gives you any other education on how you can actually heal your body.

The reality here is that conventional medicine and functional medicine are answering two completely different questions. Conventional ranges are built to catch disease, to keep you out of the hospital, and to make sure you’re not actively dying. That’s an important job and I’m grateful for health care professionals that are in the conventional world that work tirelessly to help others that are in emergent situations. But, the system was never designed to promote vibrant health or to tell you whether you feel like yourself. They were trained by a Big Pharma perspective to hand you a script and send you on your way. No other questions asked. The defense: well, we are following protocol. Really?

Unfortunately, the sad reality is that you become the collateral damage in a system that is designed to keep you sick and helpless. And, mind you, I have worked in multiple hospitals over a 22-year time span and know a lot about the inner workings and underbelly of the system.

So, let’s talk about how I actually look at labs, because I think it matters that you know it shouldn’t be guesswork.

I don’t zero in on one marker and declare a verdict. I look for patterns. Patterns over time are even more helpful. A blood glucose that’s a little high next to a BUN that’s a little low next to a TSH that’s crept up over three years tells me a story that no single number could tell on its own. You won’t get this kind of pattern-reading from a symptom checker or an AI chatbot. This comes from years of sitting across from real women and learning to read their whole story, not just their numbers on a page. Your body is always trying to hold a tight, narrow window, because it’s trying to maintain homeostasis in the body and keep you alive above everything else. I believe that’s by God’s amazing design. I believe you were built with a kind of wisdom that’s still trying to protect you even when it’s exhausted. But surviving and thriving pull from different reserves, and blood work is really only a snapshot of the surviving part. One panel on one Tuesday morning doesn’t tell me who you really are. It tells me what was going on that morning, but does not do the work of a thorough intake.

The pearl: normal is the floor your body refuses to fall below. Optimal is where you actually get to feel alive in your body again, have aspirations and goals, and flourish and love your life again.

I used to think that if my own bloodwork looked unremarkable, the conversation was over. I don’t believe that anymore. Last year I went through months of joint pain I couldn’t explain. My labs looked fine. I’m the person other women call when their labs look fine and they still feel awful, and there I was, doing the exact same thing to myself, waiting for a number to give me permission to believe my own body. It turned out I was significantly low in some specific minerals and nutrients that never even get checked on a standard panel. Once I started correcting it, the pain that had followed me around for the better part of a year started to lift. I tell you that not to hand you a supplement recommendation, as I made multiple tweaks along the way to support my aging body, but because I think it’s important you know I’m not asking you to trust something I haven’t lived myself.

This is the whole reason I build every protocol the way I do. Not chasing one lab value, and not treating a number instead of a woman, but looking at the full terrain, the patterns across systems, the raw materials your body actually needs to run on, and asking a different question than the one you’ve been asked for years. Not “is this technically within range,” but “is this actually where you feel strong, clear, energetic, and like yourself again.”

True healthcare should start with asking women thought provoking questions. Questions such as “what is in your life that you can no longer stomach?” “How is your relationship with your spouse and partner?” “What gives your life meaningful purpose?” “Do you have a faith or a community that can serve as an anchor when you are going through hard times?”

This is the reason a woman can walk away from a doctor’s office with a folder full of normal labs and still know, deep down in her body, that something isn’t right. She’s not imagining it. There simply has not been enough investigation into why she is feeling the way she is. You see, conventional medicine is a science, but the art of it has been taken out. The deep connection from human to human and the true lived experience of the individual has been discarded for profit above all things.

I’m going to spend the next article next week walking you through exactly how I read a lab panel, line by line, the same way I do it on a deep dive call, so you can start looking at your own numbers with different eyes. This is not a replacement for your doctor, but some education and encouragement so that you stop feeling like a stranger in your own body.

If that’s something you want in your inbox, subscribe here and share if you feel compelled. Women deserve intelligent conversations that address what is keeping them up in the middle of the night, help them connect the dots from a root cause perspective, and restore their faith in their body’s miraculous ability to heal.

Subscribe now

If this described you, someone you love probably needs to read it too.

Share

Big hugs,

Dr. Mandy 🙌

In the last article I published in this hormone series, I told you hormone replacement has only really existed for about fifty years, and that a lot of what gets called “hormone therapy” is in reality synthetic. Not bioidentical or identical to the innate hormones our body produces. I want to unpack this now and what this means for you right now as you navigate the perimenopause era and beyond. This distinction changes how you should think about everything the news is telling you.

HRT, in the conventional sense, often includes synthetic progestins and non-bioidentical estrogens. The means that they are manipulated in a lab. Premarin is the most familiar example, conjugated equine estrogens extracted from pregnant mares’ urine. It’s not human estradiol, and it’s not a lab-synthesized molecule either. It’s a different species’ estrogen entirely. Prempro combines that with a synthetic progestin, medroxyprogesterone acetate, into a single pill. Neither is identical to what your own ovaries make. BHRT, on the other hand, uses molecules that are structurally identical to what your own ovaries actually produce, bioidentical estradiol and bioidentical progesterone. It is the same molecule, not a look alike from another species or a lab.

Estrogen deserves the same fair treatment here that I want to give progesterone. It’s not just the hormone getting blamed in headlines. It’s genuinely the most effective treatment we have for hot flashes and night sweats, and it protects bone density in a way almost nothing else matches. It also treats the tissue changes now called genitourinary syndrome of menopause, vaginal and urinary symptoms, directly at the source. None of that means every woman needs it. It means the benefit side of the ledger is real, not marketing, and dismissing estrogen outright would be just as inaccurate as treating it as risk-free.

That distinction isn’t simply a hunch. Chakmakjian and Zachariah’s 1987 study found that oral progesterone produces steady, measurable blood levels. The PEPI trial, a landmark study through the 1990s, confirmed oral micronized progesterone protected the uterine lining just as well as the synthetic progestin it was tested against, verified with actual endometrial biopsies, not just a lab number on a page.

The creams, on the other hand, tell a different story. A more recent review found transdermal progesterone doesn’t reliably protect the uterine lining at all. Absorption through skin is inconsistent, woman to woman and day to day, which means a cream that looks fine on the label can quietly leave her under-protected without her ever knowing it.

This matters most in exactly the situations where a woman can’t afford that unpredictability. PCOS is the clearest example. When ovulation doesn’t happen, no progesterone gets made that cycle, and estrogen keeps building the uterine lining with nothing there to balance it. That’s the same underlying pattern behind a lot of what gets grouped under estrogen dominance, PMS, difficult periods, cysts, endometriosis, too much estrogen relative to too little progesterone. And it’s the same principle whenever a woman is on estrogen replacement. Estrogen needs to be opposed by progesterone to protect the uterus, if she still has one, and if the form of progesterone she’s using isn’t actually absorbing reliably, that protection isn’t happening the way it looks like it is.

Most women in the United States do not know this, but European women are largely prescribed bioidentical hormones versus synthetic hormone replacement. Oral micronized progesterone, the kind most common across Europe, is a pharmaceutical product too. But, here’s the real distinction: you can’t patent a molecule that already exists in nature, so a company either alters the molecule into something new and patentable (a progestin, fast and highly profitable, and the US default) or patents the delivery of the real molecule instead (exactly what happened with oral micronized progesterone in Europe which is a harder, slower road). So, what actually happened wasn’t pharma versus no pharma. It was which road got taken, and that default has real consequences for how a woman’s body responds.

And, here is where things have gotten interesting from a historical research perspective. The Women’s Health Initiative, the study that scared a generation of women off hormone therapy, actually ran two arms. Women with a uterus got estrogen plus a synthetic progestin. Women who’d had a hysterectomy got estrogen alone. The combined group showed a real increase in breast cancer, sustained for almost twenty years. The estrogen-alone group did not. Same estrogen, different progestin status, different outcome, buried under two decades of headlines that just said “hormones cause cancer.” Unfortunately, in the research arena, things get buried, data gets misconstrued, and the truth does not always prevail. Instead, we end up with half truths versus outright blatant lies that makes it harder when trying to read between the lines.

Interestingly, a 2000 study in Circulation found oral estradiol, unlike transdermal, measurably improved endothelial function and cholesterol within weeks. And here’s a piece that often gets lost: the WHI’s oral arm used conjugated equine estrogens, not bioidentical estradiol, and a later JAMA Internal Medicine study found oral CEE carried roughly double the clotting risk of oral bioidentical estradiol, backed by an actual clotting-propensity marker in the blood. It is important to know this from a biochemistry perspective – the molecule matters. Separately, route matters too, since oral estradiol still edges out transdermal on clotting risk, because the same liver first-pass that raises clotting factors is what improves the lipid panel. Two real variables are usually flattened into one debate, unfortunately.

There’s a third delivery form for hormone replacement worth naming too: pellets, inserted under the skin and releasing estrogen steadily over three to six months. Like a patch, they skip the liver first pass, and newer research shows they can hold stable, near-physiological estradiol levels that control symptoms and support bone density. But, NAMS (the North American Menopause Society) has flagged a real concern here as well: pellets aren’t standardized the way a patch or pill is and dosing can run higher than intended. There is less oversight of exactly what a woman is getting. That’s not a reason to rule pellets out. It’s the same theme running through this entire piece.

Pellets can be legitimate tool, and the outcome still depends entirely on who’s placing it, how they are monitoring the hormone replacement, and how closely they are following that patient. This is a risk benefit analysis that generally does not get walked out between a prescriber and the patient. Frankly, I don’t love the pellet option. Once pellets are inserted, there is no going back and, for me, permanent is risky. I am going to share an example here. If a woman has an estrogen pellet placed in the perimenopause era when she still has sufficient hormone production of estrogen, this can cause the 5 Bs that Dr Rouzier references: Bitchiness, bloating, breast tenderness, bleeding, and breakouts. I talked about this in the first article in this hormone series. Once the pellet is placed, it can not come out. Hormone pellets are placed in the subcutaneous fat tissue to dissolve and disintegrate on their own over three to six month. If the woman ends up with estrogen dominance and is miserable, then there are other therapies that have to be used to lower the estrogen including opposition with progesterone or an aromatase inhibitor to lower circulating estradiol by blocking peripheral conversion. Sounds complicated and makes you pause, right?

I’m not sure either side is asking the question I care about most, though. Hormones are almost never the villain. They’re the downstream output of everything happening upstream, the minerals, the stress load, the sleep, the nutrient status a woman’s body has actually had to work with. No amount of debating oral versus transdermal, or synthetic versus bioidentical, fixes what put her hormones in an imbalanced state to begin with.

Hormone replacement, synthetic or bioidentical, is not just a science. It’s an art, and that scares me more than any black box warning, because the margin for error is real and depends entirely on who’s holding the prescription pad. When a woman is on estrogen, her progesterone has one non-negotiable job: protect the uterus from what unopposed estrogen does to that lining over time. Get the form, dose, or sequencing wrong, and it isn't a small miss. This is exactly where I see the widest range of skill from one prescriber to the next, almost entirely a function of training, not intent.

Dr. John R. Lee, an OBGyn who studied this before most of the field was paying attention, coined the term estrogen dominance. He wrote about the idea that a lot of what gets blamed on menopause isn’t a true estrogen deficiency at all. Progesterone can fall to nearly nothing while estrogen only drops by less than half, so a woman can end up relatively estrogen-dominant even as her actual number goes down. Dr Lee’s answer was topical progesterone cream, and for a lot of women working through that ratio problem, PMS, fibrocystic breasts, fibroids, cream genuinely helps. I personally have used the cream with good success and am a proponent.

But, here is where I want to be precise instead of picking a side, because both things are and can be true. Progesterone cream and oral progesterone aren’t competing for the same job. Progesterone can be helpful in correcting an estrogen-dominance pattern. I have seen it firsthand. Oral progesterone, on the other hand, has the tissue-level research behind it for protecting the uterus in a woman taking estrogen. A prescriber who doesn’t understand that distinction can hand a woman cream to do a job the research doesn’t support cream reliably doing. That’s not synthetic versus bioidentical, and it’s not Lee versus Rouzier. It’s a training problem.

By Dr. Lee’s own read, most women aren’t actually estrogen deficient at all. The exception tends to be very lean or smaller framed women, since body fat itself produces estrogen through aromatization, and very little of it may mean genuinely needing more support than the body can make on its own. That’s my clinical read, not the final word, and it’s one of the places the field itself hasn’t fully agreed.

Dr. Aviva Romm, an MD, herbalist, and midwife that I’ve trained under, has shared with our practitioner group that she doesn’t believe every woman needs hormone replacement either. She sees real value for testosterone, specifically for low libido, a narrower claim than the marketing usually makes, but exactly where the evidence is strongest. The Endocrine Society’s own 2019 guidance backs testosterone for that one clearly supported use and stops short of endorsing it for the energy, mood, or muscle claims it often gets sold on.

None of this changes the sequence I care about most: diet, sleep, stress resilience, and exercise or movement, the foundation everything else sits on top of. Hormone replacement, done well, can genuinely help a woman feel like herself again, but it was never meant to replace the deeper work of building a body that can hold its own hormones steady. Hormone replacement is icing on the cake. You need to have the foundations dialed in or your building health on shaky ground. Your prescriber needs training well beyond what most OBGyn programs cover to get form, dose, and sequence right together, for your specific body. That’s not a criticism of OBGyns. It’s an acknowledgment that this nuance was never really taught to most of them as a specialty of its own. Most doctors are not hormone experts or specialists although they have prescribing abilities.

So why don’t more conventional providers talk about any of this? I don’t think it’s dismissiveness. I think it’s genuinely difficult to get accurate hormone levels on women in perimenopause when hormones are swinging wildly. Hormone levels in perimenopause don’t sit still long enough to measure cleanly, draw blood Tuesday and you might get a different number Thursday, and when a provider is trained to treat a single lab value as the answer, the simplest path is often whatever protocol is standardized, even if it’s not the molecule your body actually recognizes.

The pearl: Bioidentical hormone replacement isn’t just about avoiding medicine or escaping pharmaceutical companies. It boils down to what molecule you’re actually putting into a body. Is the enviornment optimized and able to convert and use those hormones once they are given?

Subscribe now

I’ll tell you something I didn’t expect to end up saying. I went through my own bioidentical hormone training assuming that once I understood it at a real clinical level, I’d feel settled enough to use it on myself without a second thought. That’s not what happened. The more I learned, the more questions I had, not fewer. I wasn’t convinced this is a tool every woman needs to reach for automatically, especially not from a longevity standpoint. I went in expecting the debate to get settled for me. I came out having to go back to my own gut instinct, the same instinct I ask every one of you to start trusting again.

Bioidentical hormone therapy can be genuinely valuable, for a season, for the right woman. I’ve watched it help women get their lives back, and I believe in it. But if what we’re actually after is optimizing health, not just managing it, I have to ask the harder question. Do we really need replacement, or do we need a body that’s finally been given what it requires to run its own hormones well in the first place?

The longer I do this work, the more convinced I am that we’ve made health far more complicated than it needs to be, chasing the next shiny object, a new supplement, a new peptide, a new protocol, when so much of what we’re missing is simpler than another prescription. A real, nutrient-dense diet. Sleep that’s actually restorative. A nervous system given permission to come down off high alert through prayer and movement. And specific minerals doing quiet, unglamorous work underneath all of it: magnesium supporting vascular tone and heart rhythm as we age, early research on boron suggesting it may influence estrogen and testosterone metabolism, and copper, a mineral almost nobody gets taught to think about, sitting at the center of how I educate women to look at hormone health in the first place. None of that replaces medicine when medicine is genuinely needed. It’s the layer most conversations about hormones skip straight past. When a woman lives in sync with her body instead of constantly overriding it, that’s where real optimization happens, long before any prescription enters the conversation.

None of that means hormone therapy doesn’t have a place. It means it isn’t the whole story or answer, and I don’t want you finishing this series thinking a patch or a capsule is the finish line. The case is simply not closed. And, some much of our modern day medical treatment focuses on a game of wack-a-mole and chasing symptoms with pills, not building foundations or actually reverse engineering the issue.

In the next article of this series, I want to walk through insulin resistance and why it deserves a much closer look before hormones ever enter the conversation.

I would love to hear what you are struggling with, what keeps you up at night, and how that is framing how your approach and perspective with your own health. Remember - health is a journey. It is a marathon, not a sprint. It is important to keep showing up and asking the questions and doing an reevaluation of the evidence as you gain more knowledge. And, I will leave you to ponder this one line from Socrates that keeps me on my toes, “The only true wisdom is in knowing you know nothing.” Stay Gutsy, my friend!

Subscribe now

Big hugs,

Dr. Mandy 🙌

This is educational content based on my clinical training and experience. It isn’t a substitute for individualized care from your own provider. Please talk to a practitioner who knows your full history before making any changes to hormone therapy.

Here’s one thing most women never hear: a fasting glucose of 94 gets called “normal” on almost every lab report. But the conventional range lets it climb as high as 99, sometimes even 120, before anyone raises a flag. By the time a number like that shows up on paper, your body’s often been quietly compensating for years.

The full breakdown — what’s actually driving it, the labs to ask for, and where I’d start — is in this month’s file.

Your first download is below👇🏻

Read more

I was told my body wasn’t capable, and that he’d likely be my only child.

I refused to accept that as my story.

I have six children now, all conceived naturally, five healthy, full-term pregnancies after him.

But that night changed everything about how I see medicine. Because I lived the thing so many of you are living right now: being dismissed, being handed a prescription instead of an answer, being told everything was “fine” when everything in my body was screaming that it wasn’t.

I couldn’t unsee it after that. How many women get rushed, managed, and sent home still sick. How “your labs are normal” becomes the end of the conversation instead of the beginning of one.

So I built the practice I wished I’d had. Naturopathic Doctor. Double board-certified in Functional Medicine. Root-cause care that honors your biology and your faith, because I believe healing is meant to tend the whole woman, not just quiet her symptoms.

That’s what this space is for. Every week, I break down one symptom you’ve been told to just live with, and show you the root cause underneath it. No fear-mongering. No fluff.

Here’s how to start:

• If you’re new, read The 7-Minute Appointment Was Never Designed to Find Your Root Cause, the whole philosophy in one place.

• If you want to understand your own body, take the "Which High-Achieving Burnout Are You?" quiz for your personalized starting point.

• And subscribe free.

  Subscribe Free

You’re not crazy. You’re not broken. You’re just not getting the full story.

Big hugs,

Dr. Mandy 🙌

The FDA pulled the black box warning off hormone therapy last November. In February, an advisory panel went further, and the commissioner said the old risk framework “came from a different era.” Hormone replacement prescriptions have nearly doubled since 2017. If you’ve spent the last twenty years hearing that hormone therapy was dangerous, and now you’re hearing the opposite, I understand the whiplash. I sincerely felt it too and wanted to know more than what we were being fed.

I want to be honest with you about where I land on this, because it’s not as simple as it sounds and the jury verdict is still out.

I ran across a message from a woman in her mid-40s, on progesterone and an estradiol patch for a few months, describing something I hear constantly in my own practice. She had two good days. Really good days. The kind where the inflammation just lifted, her thoughts cleared, her body felt like her own again. She said she didn’t realize how noisy the symptoms had become until they briefly turned off. In her words, she felt like she was a frog in a pot of boiling water. And then, right after her last dose of progesterone that cycle, the symptoms returned and escalated quickly. Whole body soreness. Swelling and puffiness. Nausea. Significant mood changes and feeling unhinged. She pondered what had happened to the version of her that showed up vibrantly for two days.

That's not a story about hormone therapy failing. But the story goes deeper than that. It's about the order it was given in. So hang with me here.

Here’s what I want you to hear. When I trained with Dr. Neil Rouzier at Worldlink Medical, he was firm about the prescription of estrogen, and it changed how I think about perimenopause completely. Mind you, I have trained with some other medical societies including A4M and they did not take a stance like this on estrogen replacement and the timing. Hormones are messy in perimenopause and there is not an exact science. It is an art as well.

The reality is that most women in this stage still have adequate estrogen levels. Estrogen is fluctuating, and sometimes wildly, but it’s still there. Progesterone is usually the one that takes a dive first and drops the fastest. So when a woman in perimenopause gets handed an estrogen script before anyone has looked at what her progesterone and other hormone levels are actually doing, she can end up with estrogen levels that are already dominant swinging even higher which is a problem. Estrogen dominance can present in many forms including heavy, painful or irregular periods, swelling and breast tenderness, fibrocystic lumps, weight gain, PMS symptoms, low energy, sluggishness and brain fog.

For perimenopause clients that are taking estrogen too early, we can see a pattern show up which Dr Rouzier coins the the 5 Bs. Bitchiness. Bloating. Breast tenderness. Bleeding that’s heavier or more irregular than it used to be. Breakouts along the jawline that weren’t there a decade ago. When I hear three or more of these symptoms together in a perimenopausal woman, especially one who’s already on estrogen, I stop and ask what her progesterone is actually doing before we go any further. I have watched this exact pattern play out with women in my own practice who came to me already on estrogen replacement, still cycling, still perimenopausal, wondering why they felt like trash instead of feeling like themselves again.

I am not telling you hormone therapy is the enemy. I’ve spent years researching and training in this field. I believe in it, at the right time, for the right woman, in the right order. What I’m telling you is that when you hear the words “you’re a candidate for HRT” and “estrogen is the first thing you need,” they should not be in the same sentence, especially in the perimenopause years, before you’re fully on the other side of it. And, as a perimenopause woman that is now 46, I have been navigating the rough waters of this mystery era myself and it is not for the faint hearted. It can be downright maddening when you are laying in bed in the middle of the night tossing and turning. Or when your joints and muscles ache so badly, you can barely stand up from the floor or drive your car. You are doing all the things. You have done an overhaul on the diet. You are taking the supplements. You exercise daily. But, something is still off.

I will die on a hill over this ~ the alternative to careless prescribing isn’t doing nothing. It’s prescribing hormone replacement in the right sequence along with dialing in the foundations of heath and this is frequently missed in the protocol.

Here’s the honest part about the data. Hormones in perimenopause don’t move in a straight line you can chart. They shift rapidly second by second, minute by minute, and hour by hour hence why it is not routine for conventional providers to test hormones in the perimenopause years. If you walk into your OBGyn’s office and ask to have your hormones tested, they will most likely look at you like you are nuts and suggest birth control. The research that’s tried to track this closely says the same thing. The pattern is different for every woman, shaped by her metabolic status, nutrition, activity level, stress in her life, genetics, and her medical history.

What I’ve come to believe, after years of watching this play out in real clients, isn’t really about one hormone at all. It’s a reckoning. She’s spent twenty years stacking habits, some good, some not, onto a body that could absorb the hit while her hormones stayed steady. Add then declining hormones showed up on the scene to climbing stress levels, caretaking for kids and aging parents, nutrient depleted foods, toxins, overexercising or under exercising, and the bucket starts to overflow. We call it a hormone problem because that’s where it finally shows up. And, we wonder why we feel like Rocky Balboa in a boxing ring with Ivan Drago.

Most of the time, however, hormones are the downstream driver, not the actual root cause. I want you to picture a crime scene as I love analogies. When the police show up, they question everyone in the vicinity. Hormones are the ones standing right there, every time, so they are the ones who get hauled into the police station for questioning. Sometimes they end up getting charged as guilty. But the person or thing that is guilty is long gone, because nobody looked past whoever was standing closest to the scene.

There can many drivers for hormone imbalances and, many times, it is a confluence of factors in my professional opinion. Excess stress in one’s life, mineral deficiencies, toxins, the Standard American Diet, lack of sleep. There are so many factors that are not investigated in the conventional world of medicine. Cortisol, many times, is a key player in hormonal imbalances as it impacts everything downstream of it, including the hormones your asking your doctor about.

I’ll be honest about something else, too. Hormone replacement, in any form, has only really been apart of medicine for the past fifty years. That’s not very long in the grand scheme of things. And a lot of what’s been studied and marketed under that name has been synthetic, built by pharmaceutical companies to be patentable, not necessarily built to match what a woman’s body actually makes and needs. That’s a different conversation than bioidentical hormone therapy, and it’s one I want to walk through properly, because conflating the two is part of why this whole topic stays so confusing. For now, just hold onto this: we don’t know nearly as much as the headlines make it sound like we know.

What I keep coming back to is this. I believe your body was designed with a wisdom and it doesn’t need to wait for a committee to catch up. Headlines change. Advisory panels reverse themselves. What your body has been quietly trying to tell you the whole time doesn’t. We avoid confronting the fact that God did create our bodies wise and intuitive, capable of healing itself when given the right conditions. Let’s be honest. We were not born with a pharmaceutical deficiency.

And, the sequence isn’t only about which hormone gets prescribed first. Before I ever get to that conversation, I’m looking at whether your body has what it needs to metabolize and balance the hormones it’s already making. Minerals like magnesium, sodium, potassium, calcium, and boron play a real role here and are completely dismissed for the next shiny pharmaceutical. Boron specifically supports how the body handles and clears estrogen rather than letting it build up unopposed. Minerals are usually one of the first things I have a woman add into their daily routine, prescription or not, because you can’t out-prescribe a body that doesn’t have the raw materials to do its own work.

The pearl: In perimenopause, progesterone is usually the hormone that needs the most support first, not estrogen. If you get that order backwards then you can end up chasing symptoms that were never about low estrogen at all.

If you’re currently on estrogen replacement and still having a cycle, even an irregular one, this is worth a real conversation with a practitioner who’s looking at your actual hormone picture, not just handing you what’s trending in the news right now. I’m not telling you to stop what your prescriber has recommended. I’m saying ask the questions and do the research and due diligence on your behalf to make sure you have all the facts. My recommendation ~ be curious and question everything!

I’ll be going deeper into what progesterone-first support actually looks like, and how to know which stage you’re really in, in the next few pieces. This is the start of a real series, not a one-off article. If you truly want to understand the complexities of hormone health and holistic solutions that address imbalances in the perimenopause era and beyond, I’d love for you to stick around!

Subscribe now

Big hugs,

Dr. Mandy 🙌

P.S. Are you in perimenopause, on hormone replacement, and dealing with any of the 5 Bs? I would love to hear from you.

This is educational content based on my clinical training and experience. It isn’t a substitute for individualized care from your own provider. Please talk to a practitioner who knows your full history before making any changes to hormone therapy.

I can’t seem to look away from the tragedy at the center of it. And I don’t think we should look away from the questions it forces us to confront either.

God did not design our bodies with a pharmaceutical deficiency.

That does not mean I believe pharmaceuticals have no place. They absolutely do, and there are situations where medication can be lifesaving. But medication is not the whole story.

Nutrient deficiencies. Environmental toxins and chemical exposures. Oxidative stress. Hormonal changes. Genetic vulnerabilities in antioxidant protection and detoxification. Metabolic dysfunction.

These can all influence the brain.

And yet our mental health system often spends far more time asking, “Which medication?” than asking, “What is happening physiologically in this person’s body?”

That question is deeply personal for me.

Three years ago, one of my daughters went through a mental health crisis of her own.

She was still a minor, and she had struggled to “fit” into the traditional educational system for years. It was a painful, long road to 18.

She was five when she was first diagnosed with a visual processing disorder. Her kindergarten teacher recommended holding her back, and I knew in my gut that wasn’t the answer.

At eight, she was diagnosed with ADHD, inattentive type.

At eleven, generalized anxiety disorder.

She was always somewhat oppositional with my husband and me, and for years I chalked much of it up to having an extremely strong-willed child. But, the behaviors took a toll on everyone in the household.

She saw psychiatrists and psychologists for years. We participated in family counseling. She completed visual processing therapy. We tried experimental treatment with a developmental optometrist. She completed an intensive sensory-processing program designed to help organize the nervous system through targeted movement and tactile stimulation.

We were trying.

We were doing what parents are told to do.

And then, three years ago, my daughter jumped from the second floor of our home into our living room.

Her siblings were there.

She landed on the steel edge of our coffee table and nearly impaled herself.

When I rushed to her side, I didn’t know whether she was alive. I didn’t know whether she would ever walk again. I called 911 without having any idea what kind of nightmare we were about to walk into.

She survived, by the grace of God.

But her injuries were significant and severe.

A lacerated liver. Emergency surgery. Exploratory surgery. Repair of a major abdominal hernia with mesh inserted into her abdomen. Weeks of an abdominal drain. Weeks of suicide watch.

And her siblings watched the entire thing happen.

Their trauma began the same instant hers did. There was no taking back what they had seen.

There was a before.

And there was an after.

Here’s another part of the story that still sits heavy with me.

She had been stable on Vyvanse 60 mg for about a year. My husband’s job changed, our insurance changed with it, and suddenly her prescription couldn’t be refilled for six days.

Six days.

That interruption was followed by one of the most devastating crises our family has ever experienced.

Then, while she was still recovering from major abdominal surgery, the system began trying to transfer her to a psychiatric facility nearly two hours away that was not a legitimate fit for her mental health needs.

We fought it.

We had to build a case with the hospital’s mental health team and plead ours with Child Protective Services so that our daughter could remain close to her family while she physically healed.

If you’ve never sat in that chair as a parent, I don’t know that I can fully explain it.

If you have, you already understand.

To this day, I carry pieces of that experience with me. I still wrestle with the guilt. The what-ifs. The moments I replay and wish I could somehow rewrite. I have carried immense guilt since her untimely accident.

I’ve kept my daughter’s identity out of my work for years, and I will continue to protect her name and face now.

But I’ve decided the rest of this story is too important to keep sitting on quietly.

Because I want women to understand something.

I haven’t navigated the mental health system only as a healthcare professional standing outside of it and offering opinions from a desk chair.

I’ve navigated it as a mom.

From inside a hospital room.

On my knees, fighting for the life of my own child.

And that experience is part of why I became relentless about understanding mental health at a physiological level.

Not simply as something to medicate.

As something to investigate.

Subscribe now

I later trained under Dr. William Walsh, whose work spans decades in biochemical psychiatry.

Walsh and colleagues, including psychiatrist Dr. John Crayton, published research reporting significantly elevated blood copper in women with a history of postpartum depression.

Walsh has proposed that for a subset of people, psychiatric symptoms may be influenced by biochemical vulnerabilities involving nutrients, oxidative stress, methylation, metal metabolism, environmental exposures, and genetics.

That does not mean every woman with postpartum depression has a copper problem.

It means there may be more physiology underneath psychiatric symptoms than we routinely investigate.

Pregnancy itself dramatically changes copper metabolism. Copper naturally rises during pregnancy, influenced in part by rising estrogen and ceruloplasmin. After delivery, those levels should begin moving back toward baseline.

For some women, Walsh’s work suggests that this normalization may not happen as efficiently.

And that matters because copper and zinc interact with neurotransmitter systems involved in mood, stress response, attention, and emotional regulation.

Through my training with Walsh and his work in Nutrient Power, I learned to look much more closely at patterns involving copper and zinc.

In Walsh’s model, elevated copper relative to zinc is associated with increased norepinephrine activity and altered dopamine signaling.

In plain English, this biochemical pattern may show up alongside symptoms such as anxiety, nervousness, panic, irritability, sleep disruption, low energy, attention difficulties, impulsivity, and mood instability.

Walsh has also described these patterns in women with hormonally influenced conditions and in some women struggling with postpartum depression or psychosis.

Again, this is not the only explanation.

Mental illness is complex.

Postpartum mental illness is complex.

And that is exactly the point.

We should be looking more deeply, not less.

When biochemical imbalances are present, addressing nutrient status may become part of a much larger treatment plan. Depending on the individual, that may include evaluating nutrients involved in copper metabolism and antioxidant protection, including zinc, vitamin B6, selenium, vitamin C, and glutathione.

Hormones matter here too.

Estrogen can raise serum copper considerably. Progesterone also influences copper metabolism, although estrogen tends to have the stronger effect. That is one reason hormonal shifts around pregnancy, postpartum, and perimenopause deserve far more attention in conversations about women’s mental health.

For postpartum women, testing copper immediately after delivery may be misleading because copper is physiologically elevated during pregnancy. Waiting several weeks allows the body time to begin regulating those levels.

If a woman continues struggling with postpartum depression, severe anxiety, or symptoms of psychosis, I believe we should be willing to investigate the physiology underneath those symptoms alongside appropriate psychiatric care.

There can be more to the story than a prescription.

There was more to the story with my daughter too.

My husband and I eventually decided to look beyond the conventional psychiatric model and explore additional avenues of care.

And my mind was blown by how little anyone had actually investigated.

We took a deeper look at her labs from a functional and biochemical perspective. Copper. Zinc. Her copper-to-zinc relationship. Pyrrole markers. Nutrient status. Other possible physiological contributors that don’t typically show up in a standard psychiatric workup. And, that most medical professionals rarely consider.

For years, no one had thought to look there.

We also worked with psychiatrists at Amen Clinics, where she underwent SPECT imaging and a more comprehensive evaluation. Whatever your opinion of SPECT imaging may be, what mattered enormously to me as her mother was that someone finally seemed interested in looking at the entire picture.

Not a fifteen-minute appointment.

Not another quick medication adjustment.

The whole child.

By the time she was twelve, we had already tried five different medications for her ADHD and anxiety.

Five.

Each one meant weeks of waiting to see whether it would help, dealing with side effects, adjusting doses, and sometimes starting all over again.

Eventually, we used GeneSight pharmacogenomic testing. It gave her prescribing team information about genetic variants that could affect how she metabolized or responded to certain psychiatric medications.

It wasn’t a crystal ball.

But it gave us information we didn’t have before, and it changed the conversation with her prescribers.

What I learned from Walsh, from Amen’s team, from pharmacogenomic testing, and most of all from fighting for my own daughter changed the way I look at every woman who sits across from me now.

Because sometimes what gets labeled a “mental health problem” is also a body under tremendous physiological strain.

A body that hasn’t been sleeping.

A body depleted after pregnancy.

A body riding massive hormonal shifts.

A body under chronic stress.

A body missing nutrients it desperately needs.

A body dealing with inflammation, metabolic dysfunction, environmental exposures, genetic vulnerabilities, or some combination of all of it.

Medication may still be part of that person’s care.

But why would we stop investigating there?

As a woman, a mother, and a healthcare provider, I have watched our medical system fail people over and over.

Usually not because the people inside of it are malicious.

There are wonderful physicians, nurses, therapists, psychologists, and psychiatrists working incredibly hard inside an imperfect system.

The problem is often the system itself.

Appointments are short. Specialties are siloed. Insurance dictates care. A psychiatrist looks at one piece. An OB looks at another. A primary care physician looks at another. And the woman living inside the body is left trying to figure out how all of those pieces fit together.

I’ve sat across from women who were told their labs were normal while their bodies were screaming otherwise.

I’ve watched women receive another prescription instead of another question.

I’ve heard some version of, “Everything looks fine,” more times than I could count.

But normal isn’t always optimal.

And symptoms are information.

Being a mother is one of the most identity-altering experiences a woman can go through.

Add hormonal upheaval.

Sleep deprivation.

Nutrient depletion.

The enormous psychological weight of caring for another human being.

Then place that woman inside a medical system that often separates mental health from hormones, metabolism, nutrition, minerals, inflammation, and the rest of her physiology.

It isn’t difficult to understand how someone can begin spiraling in ways that horrify even the person experiencing them.

Watching the Lindsay Clancy trial has reminded me of something I already knew but needed to hear again.

We can do better.

Women’s voices need to be heard, not simply documented and medicated.

We need better psychiatric care.

We need better postpartum care.

We need physicians willing to collaborate across disciplines.

We need appropriate medication when medication is needed.

And we also need the courage to keep asking why.

Because a woman in crisis deserves more than one lens through which to understand what is happening inside her body and brain.

She deserves all of them.

The shift: Mental health is not separate from physical health. The brain lives inside the body, and we should be willing to investigate both.

I want to hear from you.

Have you been following the Lindsay Clancy trial? What has this brought up for you as a mother, as a woman, as someone who has navigated your own mental health, or as someone who has watched a person you love navigate theirs?

Drop it in the comments.

I read every one, and I’d rather have this conversation out loud with you than leave it sitting quietly in my own head.

If this is the kind of writing you want more of, I’d love to have you here. If this resonates with you and it could be helpful to a friend or loved on in need, I would appreciate the share!

Subscribe now

Big hugs,
Dr. Mandy 🙌

A few weeks ago I told you Safety was the pillar most of us skip straight past, and that I’d come back to what it actually looks like day to day. So here’s the first real, practical piece of it. Not a mindset shift this time. An actual thing you can make in your kitchen this afternoon.

What’s actually happening when you’re running on empty

Your adrenal glands respond to stress by releasing cortisol, and in short bursts, that’s exactly what it’s designed to do. It mobilizes energy, sharpens focus, gets you through the moment that needs you sharp. The problem isn’t cortisol itself. It’s what happens when the moment never ends.

When cortisol stays elevated for weeks or months instead of hours, the body shifts into what’s sometimes called a catabolic state, breaking down tissue and reserves faster than it can rebuild them. This isn’t a fringe idea. Chronically elevated cortisol has been shown to suppress lymphocyte activity, which is part of why women under prolonged stress tend to catch every cold that comes through the house. It also disrupts the gut barrier and shifts the microbiome toward a more inflammatory state, which is a big part of why stress and gut dysfunction so often show up together, not as two separate problems, but as one.

Add hormone imbalance to that list too. The same stress pathway that keeps cortisol elevated also interferes with the signaling that regulates reproductive hormones, so it’s not a coincidence when a woman under chronic stress also finds her cycle, her energy, and her mood all sliding at once.

None of that resolves overnight. Diet and lifestyle changes that support this system take time, sometimes months, before a woman feels the shift. That’s frustrating to hear when you want relief now, but it’s the honest timeline, and it’s part of why I keep coming back to the basics instead of chasing something flashier.

Why vitamin C, sodium, and potassium specifically

This is where the adrenal cocktail comes in, and it’s usually the very first thing I have a woman start when we begin restoring balance in her adrenals.

Vitamin C isn’t just a general immune-support nutrient here. The adrenal glands hold some of the highest concentrations of vitamin C anywhere in the body, and they use it directly to help make cortisol and the catecholamines involved in your stress response. Research has actually shown adrenal vitamin C gets released into the bloodstream specifically when the adrenal glands are stimulated, which tells you how tightly the two are linked. When a woman is under chronic stress, that reserve is being pulled from constantly, and whole food sources, citrus, berries, leafy greens, help refill it in a form the body recognizes and uses efficiently.

Sodium and potassium matter for a related but different reason. These are the electrolytes your adrenal glands lean on to regulate blood pressure and keep your nervous system properly signaling, calm when it should be calm, alert when it should be alert. Chronic stress burns through both faster than most of us realize, and low-sodium diets, which so many women have been taught to follow, can actually work against adrenal recovery rather than support it.

Put those three together, vitamin C, sodium, potassium, and you get something simple that hands the adrenal glands exactly what they’re depleted of.

The basic recipe:

• 4 oz fresh squeezed orange juice

• ¼ tsp cream of tartar

• ¼ tsp sea salt

That’s it. Stir it together and drink it, ideally away from food, mid-morning or mid-afternoon, whenever your energy tends to dip.

If you’re sensitive to citrus or just don’t love orange juice, there are good alternatives that still deliver the same core electrolytes:

• Coconut water in place of the orange juice, naturally rich in potassium already

• Tart cherry juice, which also brings some anti-inflammatory benefits

• Watermelon juice, another solid potassium source with a lighter taste

Whichever base you choose, keep the sea salt and cream of tartar, that’s where most of the sodium and potassium actually comes from. Start with a smaller amount than the recipe calls for if you’re not used to it, some women feel it right away, and easing in is completely fine.

One a day is a good place to start. Some women eventually work up to two, once mid-morning and once mid-afternoon. You don’t need to overthink the timing, just aim for away from meals, and see how your body responds.

This is such a small thing to add to your day, and it’s usually where I see the first shift. Not a dramatic one. Just a little more steadiness by 3pm. A little less of that wired, running-on-empty feeling by evening. And underneath it, something bigger starting to rebuild, immune resilience, hormone signaling, a gut that isn’t constantly on the defensive.

That’s what safety actually looks like sometimes. Not a total life overhaul. Just handing your body the minerals it’s been asking for, in a form as simple as juice and salt, and giving it the time it actually needs to rebuild what chronic stress has quietly been taking apart.

Subscribe for Free

I’ll keep sharing the practical, everyday pieces of this work, not just the philosophy behind it. If that’s useful to you, I’d love to have you here for what’s next.

Subscribe for Free

Big hugs,

Dr. Mandy 🙌

A few weeks ago I told you I’d quit Orange Theory after ten years and that I’d be back to share what I’m actually doing instead. I’ve had a few of you ask since then. So here it is, the real, unglamorous version, not a protocol in a box, but the four things I keep coming back to when I ask what my body actually needs instead of what I think she should be doing.

I didn’t sit down and invent these. They showed up, one at a time, as I paid attention to what actually helped and what quietly made things worse. Looking back, they sort into four categories. I’ve come to think of them as the four things every body needs, in this order, before anything else matters.

Safety

This one came first, and it came hardest, because it meant admitting something I didn’t want to admit. My nervous system had been living in “go” for years. Six pregnancies, six c-sections, twenty-four years of raising kids, a decade of pushing myself at Orange Theory because pushing was the only mode I knew. None of that is inherently wrong. But a body that never gets the signal it’s safe to rest doesn’t heal, no matter what else you throw at it.

You know the feeling. You’re lying in bed at 11pm with your to-do list running on a loop, or you catch yourself holding your breath answering an email that shouldn’t matter this much. That’s not a personality flaw. That’s a body stuck in “go,” and it will burn through every supplement you throw at it trying to compensate.

So the first thing I changed wasn’t a supplement or a workout. It was permission. Permission to walk instead of run. Permission to skip a class instead of gutting it out. Permission to let a day be slower than I planned. Some mornings that looks like five minutes on the porch with coffee before anyone needs me for anything. Some nights it’s putting the phone in another room instead of scrolling until my eyes give out.

That sounds almost too simple to count as a protocol. It isn’t. It’s the foundation everything else sits on.

The pearl: your body cannot build anything on top of a “go” signal that never turns off. Rest first. Everything else is just noise until she feels safe enough to receive it.

More on nervous system safety soon, subscribe to make sure you catch it

Stability

Once safety is in place, the body can actually build something instead of just surviving. This is where the physical shift happened for me: yoga, pilates, and weight lifting, in place of high-intensity intervals five days a week. Not because intensity is bad, but because my body at this stage needed strength built slowly, with control, instead of strength chased at a sprint.

I’ll be honest, quitting the sprint felt like quitting on myself at first. There’s a particular kind of pride in leaving a class drenched and depleted. It took me a while to realize that depleted is not the same thing as strong, they just feel similar in the moment because both leave you tired.

Stability also means minerals. This is where I lean hardest on my own training, using HTMA to see what’s actually happening at the cellular level rather than guessing. Most of us are depleted in ways a standard blood panel will never catch, and depletion is exactly what makes a body feel like it’s failing when it’s really just asking for something specific. It’s the difference between a woman white-knuckling her way through another workout on fumes, and a woman who’s actually replenished enough to meet the day.

Boron is one I’ve been paying closer attention to lately. It’s a mineral almost nobody talks about, but it plays a real role in how your body handles calcium and magnesium, the ones that keep bones and joints functioning the way they should. Modern soil and modern diets have quietly stripped a lot of it out, and I think that gap matters more than it gets credit for, especially once perimenopause puts extra pressure on bone and joint health. It’s part of why I’ve leaned into it myself this year.

The pearl: strength built slowly still counts. You are not falling behind because you traded sprints for slow, controlled movement. You’re finally building something that lasts instead of something you have to keep proving.

Strength

This is the pillar I underestimated for the longest time. Strength doesn’t come in pill form. It’s the people, the faith, the community that holds you when the plan falls apart. For me that’s my husband Joe, carrying every box without complaint on a hard moving day. It’s my kids watching me finally rest instead of push, learning by example instead of lecture. And it’s my faith, trusting that the body I was given was designed with wisdom in her, even when she doesn’t cooperate with my timeline.

I used to think needing support was its own kind of failure, like if I were strong enough, I wouldn’t need anyone carrying part of the load. I don’t believe that anymore. The women I know who are actually thriving, not just performing thriving, all have this in common. They let people in before the crisis forces them to.

It’s also you, honestly. Writing this out loud, in front of people who are living some version of the same thing, has become its own kind of support I didn’t expect to need.

The pearl: asking for support isn’t the failure. Waiting until you’re depleted to ask for it is. Let people in on the ordinary Tuesday, not just the emergency.

Synchronicity

Last, and only last, come the actual clinical tools. Bloodwork that goes deeper than the standard panel. Food sensitivity testing, so I’m not guessing what’s quietly working against me. HTMA, again, to track minerals over time instead of once. These matter. But they only work once safety, stability, and support are already in place. A perfect lab result means very little in a body that still doesn’t feel safe enough to rest.

I see this order get reversed constantly. A woman spends hundreds of dollars on the perfect panel, the perfect supplement stack, the perfect protocol, while she’s still running on four hours of sleep and answering emails at midnight. The data was never the missing piece. The data just tells you what your body has been trying to say for months, once you’re finally ready to hear it in that order.

The pearl: the fanciest lab panel in the world can’t out-test a nervous system that never gets to rest. Synchronicity come last for a reason. Don’t skip to the end.

That’s the real answer to what I’m doing differently now. Not a 12-step plan. Not a supplement stack. Four questions I keep asking, in this order: Is she safe? Is she stable? Is she supported? And only then, what do the systems actually show me?

Subscribe now

I still don’t have it all figured out. I don’t think that ever fully stops being true. But I’ve stopped needing a perfect protocol to trust the process, and these four pillars are what I hold onto instead.

If you’ve been collecting supplements and protocols for years and still don’t feel like yourself, I want you to hear this: you might not need more. You might need to go back to the beginning, and ask whether your body feels safe first. Everything else builds on that.

I’ll be digging deeper into each of these four pillars in the coming weeks, starting with what safety actually looks like day to day, because it’s the one most of us skip straight past.

If any part of this is where you are right now, I’d love to have you here for what’s next.

Big hugs,

Dr. Mandy 🙌

I grew up an athlete. Competitive to the bone. Pushing my body to the edge was never an issue, it was the whole point, it was how I knew I was doing it “right”. I loved sports and it is where I found a lot of my worth and identity. Soccer, softball, volleyball, gymnastics and tumbling. I did it all. So when Orange Theory opened in my hometown back in 2016 and I became a founding member, it made total sense. I loved it. It worked for me for years. It lit me up! After each session, I felt strong and accomplished and, I was officially addicted to the cortisol challenge.

Then three years ago I ran the mile for distance at Orange Theory and my knee never really forgave me for it. I pushed through an international family trip to France with every anti-inflammatory supplement, pain patch, Tiger Balm, red light you could think of. You name it, I used it.

Patellofemoral syndrome is what my sports medicine chiropractor officially named it. I did six months of chiropractic care, acupuncture, and massage, weekly visits, just to get back to walking normally. I got better. I worked on my form. And then over the next two years, the same kind of thing kept showing up in different places. A hip. A shoulder. My low back. Nothing catastrophic, just this steady, low hum of my body telling me something wasn’t right, and me not fully listening. It was frustrating. As an occupational therapist, naturopathic doctor, and double board certified functional medicine practitioner, I had all the tools. But I did not have it all figured out.

I finally quit my Orange Theory membership this year. 10 years after I walked in as a founding member. Not because I failed at it. Because my body had been asking me to for a while and my competitive streak didn’t want to hear it. The athlete in me wanted to push through as that is what I did. I recognized that my strength was also my greatest weakness. I finally arrived at the realization that I could not fix my issues continuing to do what I do. So, I threw in the towel. The practitioner in me finally won that argument.

I tell you this because I think we’ve all absorbed the same lie somewhere along the way: that doctors have it figured out, that there’s a protocol for everything, and if you’re still struggling it’s because you’re not trying hard enough or you haven’t found the right pill yet. I’ve spent 24 years raising kids, six pregnancies, six c-sections, and the last three years walking through perimenopause on top of it, and I can tell you plainly. Nobody handed me a manual. I’ve had to learn my own body the same slow way I’m asking you to learn yours.

My body is not the same body it was three years ago, or five, or ten. And instead of fighting that, I’ve started listening for what it’s actually trying to say. Sometimes it whispers, a little stiffness, a little fatigue you can talk yourself out of. Sometimes it speaks up, a flare that won’t quiet down with rest. And sometimes it shouts, and you don’t get to ignore a shout.

In homeopathy we talk about healing happening in reverse order, that things can get worse before they get better as the body works its way back out through old layers. That idea used to unsettle me. Now I find it steadying. It means the setback isn’t proof that something is broken. It’s often proof that something is finally moving.

The hardest part isn’t the symptom. It’s the waiting. We live in a culture built for instant relief, and the solution is almost always some version of a pill. Sometimes it works. Sometimes it doesn’t touch the real problem at all. And sometimes it works for a while and then quietly stops, and you’re left wondering what actually happened in your body underneath it.

I believe our bodies were built with a kind of wisdom in them, a design that’s still trying to protect us even when it’s exhausted and out of balance. Energy, strength, sleep, hormones, these are all just the body’s language. The real damage happens when we suppress that language instead of translating it. When we medicate the symptom and never ask what it was pointing to.

That’s the shift I keep coming back to, both in my own healing and with the women I work with. Not “how do I make this stop,” but “what is this trying to tell me.” Those are two different questions, and they lead to two very different paths.

Here’s what I’ve learned to trust instead: the timeline is not linear, and it was never supposed to be. It’s hills and valleys. A step forward, a flare, a plateau, another step forward. If you’re in a valley right now, that doesn’t mean the last six months of work didn’t count. It might mean the opposite.

I still don’t have it all figured out. I’m not sure any of us ever fully do. But I’ve stopped needing to have it figured out in order to trust the process, and that’s been its own kind of healing.

If you’ve ever sat across from a doctor who told you everything looked fine while you sat there knowing it wasn’t, I want you to hear this. You’re not imagining it, and you’re not failing at healing just because it isn’t linear. In the coming weeks I’ll be sharing more about what I’m actually doing, in my own protocol and my own life, to age well instead of just aging.

If this is where you are right now, hills and valleys, tired of hearing “your labs are normal,” I’d love for you to stick around. I’ll be back next week with more.

Big hugs,

Dr. Mandy 🙌

Hi friend,

You know when you hit that wall. It’s not just tired-tired. One minute you’re functioning, the next you’re staring at your screen wondering how you’re supposed to finish the day on the fumes you’ve got left.

Maybe you’ve blamed the caffeine wearing off. Maybe you’ve blamed your age. Maybe someone — a doctor, a friend, your own inner voice — has told you this is just what your late 30s, 40s, or 50s feel like now.

I want to challenge that today, because I don’t think it’s true. And I’ve watched too many women prove it isn’t.

Here’s the thing about that 2pm crash: it’s not random, and it’s not aging catching up with you. It’s your body sending you a very specific message — and most of us have never been taught how to read it.

When your body doesn’t have what it needs upstream — the minerals, the stress-response support, the raw materials it depends on — it doesn’t just quietly struggle in silence. It sends a signal. For a lot of women, that signal shows up right around 2 or 3pm, when the stress hormones that got you through the morning start to dip and nothing steps in to catch you.

That’s not a willpower problem. That’s not a “you just need more coffee” problem. That’s a depletion problem — and depletion is fixable in a way that “getting older” is not.

Let me tell you about Lindsey.

Lindsey is a widowed mom of two here in Indiana. A former healthcare provider. By the time she found me, she’d already spent two and a half years in therapy, EMDR, and massage — doing everything “right” — and still felt like a shell of herself by every afternoon.

Her labs? Normal. Every time.

“My labs were normal,” she told me. “I wasn’t.”

Five months in, I asked her what changed. She didn’t talk about her labs.

“I feel like myself again,” she said. “My confidence, my feeling like a woman again — it’s been so worth it to just be me again.”

Individual results vary.

If Lindsey’s doctor missed all of that — normal labs, five years of decline, a crash every single afternoon — what has yours missed?

I see this on almost every consult call. A woman describes her 2pm crash like it’s a personal failing — like she should just be able to push through it. And I always tell her the same thing I told Lindsey: your body is not failing you. It’s responding to conditions you are asking it to function in. And conditions can be changed.

That’s the whole shift. Not “push harder.” Not “wait it out.” Look upstream, rebuild what’s missing, and watch the crash — the fog, the mood dip, the desperate need for a nap you can’t take — start to resolve on its own.

This is exactly what I’ll be walking through live on Tuesday, July 14th at 5pm CST — a free webinar where I’m breaking down why “normal” labs so often miss what’s actually driving fatigue, mood, and hormone chaos, and what the upstream picture actually looks like when someone finally gets the full one.

If you’ve been white-knuckling your way through the afternoons for months (or years) — I’d love to have you there.

Save My Seat

Big hugs,
Dr. Mandy 🙌

P.S. — If this is your first time here, welcome in. I write about the real, upstream story behind hormone chaos, burnout, and the "you're fine" gaslighting so many of us have lived through. Subscribe below so these land in your inbox every week — not just when I happen to catch you here.

Count Me In

I’ve got sparklers in a bucket, watermelon in the fridge, and my youngest who is now a certified teenager (he just turned 13 on June 18th) has already asked eleven times when we’re eating. It’s chaotic. It’s loud. It’s exactly what this weekend is supposed to be.

And in between the chaos, I keep thinking about freedom. Not just the fireworks-and-flag kind — the kind that shows up on my calendar every week in a different woman’s voice.

Thanks for reading! Subscribe for free to receive new posts and support my work.

Subscribe now

I’ve had a lot of consult calls lately. And no matter where the woman on the other end of the call lives, or what her labs say, or how many letters are behind the last doctor’s name — the story is almost always the same.

“They told me everything looks normal.”

“I’ve done the meal plans. The macros. The generic supplement bundle everyone in the Facebook group is taking.”

“I know my body. And I know I am not okay.”

She’s tired in a way that sleep doesn’t fix. She’s tried the cookie-cutter plan — the one built for a hundred thousand women who are not her — and it didn’t hold. And somewhere in the middle of being told she’s “fine,” she started to wonder if the problem is actually her. If she’s just being dramatic. Ungrateful. Too much.

She is not too much. She has been given too little — too little listening, too little investigation, too little look.

Here’s what I keep coming back to: normal was never the goal. Normal is just the average of a population that isn’t well. And “you’re fine” is not the same thing as you are thriving.

That’s not freedom. That’s just permission to keep functioning while you quietly fall apart.

Real freedom — the kind we’re supposedly celebrating tonight with sparklers and flags — has to include freedom over your own body. Freedom from being handed the same plan as every other woman in the room. Freedom from a system that only knows how to ask “do you have a diagnosable disease?” instead of “what is your body trying to tell you?”

Galatians 5:1 says it plainly: “It is for freedom that Christ has set us free. Stand firm, then, and do not let yourselves be burdened again by a yoke of slavery.”

I think about that verse differently now than I did a decade ago. Because I have watched so many women get free of a yoke they didn’t even know they were wearing — the quiet, exhausting belief that this is just what aging feels like, that this is just what being a mom feels like, that this is just who they are now.

It isn’t. It never was.

I know this in my own body, not just in my little online wellness space. I was told at twenty-two that mine wasn’t capable — that I’d most likely never have another child. I refused to build my whole life around someone else’s verdict. Five healthy pregnancies later, I can tell you: the body is not the enemy. It has never once stopped trying to heal. It has just been waiting — sometimes for years — for the right conditions.

That’s true of your hormones. It’s true of your gut, your minerals, your energy, your sleep. And if I’m honest, it’s true of your soul too. We were not made to just get through the day. We were made to build something with it — with intention, with strength, with joy. That takes a body that has what it needs, not a body that’s been handed a one-size-fits-none plan and told to make it work.

So this Fourth of July, in the heat, with the watermelon dripping and the fireworks waiting for dark — I want to ask you the same thing I ask the women on my consult calls:

When is it your turn to be free?

Not free from responsibility. Not free from the mess of a full life — the kids, the job, the laundry, the heat index warnings. Free from settling. Free from “normal.” Free from believing that tired, foggy, and barely hanging on is just the cost of being a woman in this season.

You’ve spent years giving everything to everyone else. Your family. Your career. Your people. It is not selfish to finally ask what your body actually needs. It is, I’d argue, one of the most faithful things you can do — because you cannot build the life you were made for on a body that’s running on empty.

I’m opening the doors again soon for women who are done with cookie-cutter and ready for a real answer. If that’s you, I’d love for you to be in the room. Watch for the details — I’ll be sharing them here first. And subscribe to this channel! I have so many good things I am going to be sharing here in the near future and I don’t want you to miss out! One thing I am going to be sharing on is SLEEP😴😴😴

Until then: stay cool, drink your electrolytes, and let this be the year you stop accepting “fine.”

Big hugs,

Dr. Mandy 🙌

P.S. — If you’re the woman who’s been told everything looks normal and you know, deep down, that it isn’t — you’re not alone, and you’re not imagining it. I’d love to have you here. Subscribe below; I write every week, on the body and the soul both, for women who are done settling for “fine.”

Thanks for reading! Subscribe for free to receive new posts and support my work.

Subscribe now

Which means I have now been a mother for 24 years. Twenty-four years of getting it wrong, getting it right, and mostly getting it real. And on a birthday like this one — the last of my six crossing into the teenage years — I find myself less focused on the cake and more on the strange, holy math of it all. Six kids. Twenty-four years. A lifetime of lessons I never saw coming.

Here’s the truth nobody tells you before you start: your children will be your greatest teachers. Not the books. Not the experts. Not the carefully constructed plan. The kids themselves.

When I set out to be a mom, I had a vision. A beautiful, perfectionistic, Type-A vision of exactly what motherhood would look like — calm, ordered, lovely. My children took one look at that vision and lovingly, relentlessly dismantled it.

My baptism into all of this came early — literally. My oldest arrived three months early, and in one night every illusion I had about being in control was stripped away. Parenting has never once gone according to my plan. And honestly? That turned out to be one of the most important lessons I needed to learn as a human being on this planet.

Because here is what I had to learn to believe, down in my bones: this is happening for me, not to me.

That single reframe changed everything. The last 24 years have held some of the hardest challenges and obstacles of my life. They have also held more joy, laughter, and blessing than I could have engineered in a thousand perfect plans. The mess and the gift came in the same package. They always do.

So in honor of Emmett, and of all six of them, here are a few of the pearls my kids have pressed into me over the years:

Trust the process. Trust the journey. Things rarely turn out the way we envision — but that does not mean there isn’t a plan. I choose to put my faith in a loving God who goes before me and is for me. When I can’t see the road, I trust the One who can.

Let go of the perfectionism. This one nearly broke me before it freed me. My husband Joe says it best: when things don’t go according to plan, kick some grass over it and move on. (He says it a little more colorfully than that.) Type-A control is a hard master. Grace is a better one.

Humility and forgiveness are non-negotiable. There are no perfect humans — not me, not my kids, not anyone. Learning to admit when I’ve wronged someone, to own the hurtful thing I said or did, has done more for my relationships than any amount of being right ever could.

Listen more than you speak. And bite your tongue when you’re triggered. Words can be the sharpest weapon in the house. I’ve learned — slowly, and the hard way — that you can be right and still be wrong. Being factually correct means nothing if your delivery is destructive. Empathy and connection win every time you choose them over the argument. Every time.

Twenty-four years in, this is what I know: motherhood is messy. Parenting is messy. And the mess is not a sign you’re failing — it’s the very place the growth happens. The plan I had was a dream. The life I got was an education. And I would not trade a single hard, holy lesson of it.

Happy birthday, Emmett. Thank you for being my last great teacher. Being your mom — being all of yours — has been the making of me.

Big hugs,
Dr. Mandy 🙌

P.S. — If you’re in your own messy, beautiful season of mothering — whether your baby is 13 months or 24 years — I’d love to have you here. Subscribe below. I write every week, on the body and the soul both, for women in the full, tender middle of it all.

Graduations. Engagements. Weddings. Mother’s Day behind us, Father’s Day ahead. The unofficial arrival of summer stretching out in front of everyone like a permission slip to finally exhale. It is a season of celebrations — of chapters closing and new ones cracking open — and somehow, even the good things can leave you spent.

Because transitions are hard. Even the beautiful ones.

I’ll tell you where I’ve been lately. Last weekend I woke up to dog poop on the floor. Not a little. Not in one place. The kind of morning where you’re barefoot before your brain has caught up, standing there thinking — this is my life — and somewhere between the paper towels and the Lysol you start laughing because what else are you going to do?

That same weekend, I helped my son Bailey — my 24-year-old — move into his new place. We carried in boxes and all the optimism of a fresh start — and then we got to the mattress that he had been sleeping on for the last year. I will not go into detail other than it was a “hand me down” and free. I will only say that there are things a mother sees and simply deals with, because that’s what love in action actually looks like on a random Saturday afternoon.

This man, my dear hubs, Joe, carried every single box without complaint. The dirty, soiled mattress was the final straw — and I have the photo to prove it😂

And then yesterday, I was dealing with my 17-year-old, Liliana — mouthy, certain she has it all figured out, and not particularly interested in my input on the matter.

If you have a teenager, you already know the particular flavor of that moment. The disrespect. The anger that isn’t really about you but lands on you anyway. The way they can say something that hits exactly the wrong nerve at exactly the wrong moment. I honestly feel that this is just a outward reflection of where they are at in their own life. The messy middle. The frustrations and disappointments that come with life. The insecurities and worthiness issues. Not knowing what they really want to do in life or where they want to go. All of it culminating in sharp and cutting words that slice at your heart.

Here’s what I’ve learned — and it has taken me longer than I’d like to admit: I don’t engage it anymore.

I breathe. I walk away. I come back to the conversation when we’re both human again.

The older I get, the more I understand the power of deep listening — and the even greater power of knowing when not to speak. When someone is truly upset, the words they need from you are almost never the ones that come rushing up in that first hot moment.

Silence is not weakness. Stepping back is not losing. Sometimes the most loving thing you can do is simply refuse to pour gasoline on a fire.

I’ve been sitting with Proverbs 31 again. Specifically verses 25 through 28:

“She is clothed with strength and dignity, and she laughs without fear of the future. When she speaks, her words are wise, and she gives instructions with kindness. She carefully watches everything in her household and suffers nothing from laziness. Her children stand and bless her.”

I used to read that and feel the pressure of it — strength, dignity, wisdom, kindness, all while carefully watching everything in her household. It felt like a checklist I was perpetually behind on.

But I’ve come to read it differently now.

She isn’t laughing because nothing hard is happening. She isn’t laughing because the chapter closing is painless or the teenager is easy or the mattress is clean. She is laughing because she knows the One who holds the future. She is anchored — not naive, not checked out, but deeply, quietly rooted in something that does not shift with the season.

Psalm 93:1 says the Lord is robed in majesty and strength. And she gets to wear that too — not as her own achievement, but as a gift. She knows who she is. She knows whose she is. And those two things together are what make her unshakeable.

The stages of parenting are on my mind a lot these days, because I am living all of them at once — and I mean that literally. I once thought once they turned 18, parenting was pretty much done. Oh, that was so far from the truth. As they grow, the continue to need your wisdom and guidance. It is just at a different level.

My youngest is almost 13 and has started to get acne. He seems to grow 1-2 inches over night and I can’t keep enough food around to fuel him. My oldest, Bailey, is 24 and just moved into his own place. Six kids spanning that entire range means I am simultaneously in every phase of this thing — holding structure for one, coaching another through hard decisions, and standing back watching my firstborn build a life that is entirely his own.

With the younger ones, you are the authority — the structure, the safety, the firm and loving no. With teenagers, you shift into something more like a coach — you ask more than you tell, you resist the urge to fix, you learn to sit with the discomfort of watching them figure things out. And with a 24-year-old out on his own, you’re something closer to a peer — present, but not hovering. Available, but not controlling. Letting him carry the mattress decisions now, even the bad ones.

There is something both humbling and clarifying about standing at this particular stretch of the road — where your youngest is just crossing into adolescence and your oldest is already on the other side of it, out in the world. You can see the whole arc from here. And what I see is this: it goes fast. The phases that feel endless in the middle of them are not endless. And the things that matter most are not the performances or the achievements — they are the moments of genuine connection you chose over being right.

The phases change. But here’s what doesn’t: you are always still their parent. That covenant doesn’t expire. The form changes. The function changes. The love does not.

And the hardest lesson in all of it — the one I keep relearning — is this: you can have a tongue, or you can have a relationship. Rarely both.

There are always things I could say. Corrections I could make. Opinions I could offer, especially to a 17-year-old who thinks she has it ALL figured out. But every time I’ve chosen the relationship over the commentary, I’ve gotten more of both. Words land better when the connection is strong. They carry weight because the relationship has roots.

Deep listening isn’t passive. It is one of the most active, disciplined, countercultural things you can choose to do — especially when everything in you wants to react.

My grandmother worked in a plastics factory for years. She didn’t have the vocabulary of wellness or root cause or any of the things I talk about in my work. But she had something I see so clearly now — a rootedness. Her words had weight because her life had roots. She had survived things. She had endured things. And when she spoke, you felt it.

That is what 2 Timothy 1:5 captures so beautifully. Paul, writing to Timothy, says: “I remember your genuine faith, which first lived in your grandmother Lois and in your mother Eunice and which, I am persuaded, now lives in you also.”

Faith passed down through generations — through women who were probably just trying to get through the day. Doing the laundry. Raising difficult children. Cleaning up messes they didn’t make. Choosing kindness when they had every reason not to.

They didn’t know the thread they were laying. But they laid it anyway.

Here is what I want to say to anyone sitting in the middle of a full, tender, complicated season right now:

The world’s accolades are fleeting. The applause at graduation fades. The wedding photos settle into an album. Summer becomes fall and fall becomes another year.

But what you are building — the character, the faith, the way you handle the hard moment with your teenager, the way you breathe instead of react, the way you show up even when it costs you — that goes forward. That is the inheritance.

She laughs without fear of the future — not because the future is safe, but because she knows the One who holds it.

You belong to Him. That is enough. That has always been enough.

Big hugs,

Dr. Mandy 🙌

P.S. — If you are in the trenches with a Liliana of your own — a teenager who has all the answers — you are not alone. Walk away. Breathe. Come back. The relationship is worth more than being right.

P.P.S. — If these reflections meet you where you are, I’d love to have you here. Subscribe below — I write every week, on the body and the soul both, for women in full, tender, complicated seasons.