Supporting the Transition into Menopause with Elizabeth Mucci

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Supporting the Transition into Menopause with Elizabeth Mucci

Menopause heralds the conclusion of a women's reproductive years. For some, this is a welcomed change, for others it’s a cruel harbinger of change that brings with it a new phase of aggravating health complaints. Ranging from hot flushes, to anxiety, sleep disturbances, depression, heart palpitations, anger and mood swings as well as a number of other physical changes, many women menopause is an unwelcomed affliction. But it doesn't have to be that way, natural medicine has a lot to offer these women to help rebalance and guide them through much more smooth transitional period.

Today we're joined by Elizabeth Mucci, who takes us through the delicate, and often disrupted, pathways leading to the negative experiences of menopause. Elizabeth shares why it's important to concentrate on supporting the central organs which send chemical messengers for normal physiological signalling. With a focus on dietary and lifestyle modification, plus judicious, directed supplementation of herbs and nutrients, we can help these women regain the vitality and resilience they have lost in the perimenopausal phase.

Covered in this episode:

[00:51] Welcoming back Elizabeth Mucci
[01:43] Defining menopause
[03:56] The clues from family history
[05:13] What is the physiology of menopause?
[11:49] A modern stressors to blame?
[14:44] Exercise and muscle mass is a crucial element
[16:49] Advice for boosting Vitamin D
[18:41] What guides supplementation intervention?
[20:42] Phytoestrogens
[22:22] The direct impact of alcohol consumption
[25:50] Managing the fears associated with menopause
[29:30] Bio-identical progesterone
[31:54] What about hysterectomy?
[35:06] Western and Chinese Herbal Medicine
[40:41] Irregular bleeding - what to be looking for
[42:17] Dialoguing with GP's and knowing when to refer on
[43:28] Incorporating acupuncture
[45:56] Final thanks to Elizabeth

Andrew: This is FX Medicine, I'm Andrew Whitfield-Cook. Joining us again in the studio today is Elizabeth Mucci.  
Elizabeth is a mentor, educator, and healthcare professional with over 17 years experience in integrative hormonal and reproductive medicine. As a scientist, nutritionist, and herbalist with a Masters in reproductive medicine, Elizabeth is a passionate health advocate whose principles as a clinician and teacher have enabled her to help thousands of patients start their families both in Australia and overseas, including the U.S., U.K., Canada, China, and Japan.  
Prior to joining Elizabeth's fertility program, most of these patients have been facing particularly challenging fertility issues that have resulted in multiple miscarriages and repeat IVF failures. 

Welcome back, Elizabeth, to FX Medicine. How are you going?  
Elizabeth: I'm doing well. Thank you.  
Andrew: Now we're going to be talking today about the perimenopause, and menopause, and post-menopause a little bit. But this is a huge topic. 
Elizabeth: It is.  
Andrew: I think, first of all, can I just clear up something that's bugged me? 
Elizabeth: Okay? 
Andrew: Menopause. The definition. It's actually a moment in time, isn't it? 
Elizabeth: Yeah. So, it's a moment in time more defined as one year from your last menstrual period disappeared, basically. Final menstrual period, a year from that. 
Andrew: And so, how well is this tracked? Like, it's just really an academic definition? 
Elizabeth: Yeah. And it depends on like, a lot of patients who come to me saying that they've menopaused but actually they haven't. Because there's so many things that can influence a regular cycle. And so, if this cycle has stopped, I suppose the doctor often will tell them, "Oh, that's okay. That's just you've gone into menopause." And often, as I get their health better, and their ovarian function better, their period comes back again. 
Andrew: But when are the main symptoms presenting for women? The perimenopausal era or pre-menopause is that what you're calling it? 
Elizabeth: Yeah, so that can happen like 10 to 13 years before you even lose your period. 
Very typically though is after the age of 45, and it can really speed up at that point. But you've been getting clues along the way, like some irregularity or maybe weight gain, maybe some palpitations, poor sleep, those sorts of things. And they 're often just, you know, the common symptoms. So they're told, "Oh, yeah, that's just common. You must be stressed or you must be..." 

Andrew: Yeah, yeah. 

Elizabeth: But, actually, could be triggers, the onset could be of menopause at that point. 
Andrew: So is 45 that age that we start looking at hormonal influences? 
Elizabeth: I'd probably go before that. I actually would. I probably about 38 is where I start to...if people say things to me, I will think, "Well, hang on, are you speeding up this process? Is there something that you're doing in your life or maybe multiple things that are actually speeding up the aging process?" And yeah, you know, we go into correcting those. 
Andrew: Do you use a family history here as a sort of, more specific indicator, to perhaps give you a clue to an earlier transition into menopause? 
Elizabeth: Oh, definitely. It will be a very typical...yeah, a very typical question that I'll ask if someone says, "Oh, I think I'm going into menopause." I’ll firstly, the first question I'll ask is, "How old was your mother when she went into menopause? 

Andrew: Right Yep. 

Elizabeth: How bad was it? And how long did she suffer with it? What were her symptoms as she was going through it?" Because it will give me clues of what things or what biochemistry I've got to try and support so that that patient transitions much more smoothly. 
Andrew: Can I ask if, you know, how we normally ask about family history where you normally talk about direct lineage. But of course, there's that issue. I know this is a tangent, but when we're thinking about, say, BRCA involvement in breast cancer. So we then talk about aunties, sisters, that sort of thing. So we are talking about horizontal lineages. Where do you go with regards to hormonal issues? And we're talking today about menopause. Do you go horizontally at all or is it direct? 
Elizabeth: Mainly direct. 
Andrew: Mainly direct.  
Elizabeth: Mainly direct, yeah. Grandparent as well. 
Andrew: I guess you could go down rabbit holes. What about your third aunty?  
Elizabeth: Yeah, yeah, yeah. No. Usually, I find it's very closely linked to the mother, actually. 
Andrew: Look, I have to admit here. In my mind, I think, "Oh, it's the ovaries giving up the ghost," when we're talking about the transition into perimenopause and the menopause. So, what's exactly going on with physiology? 
Elizabeth: Right. So there's a few things that are...actually it's quite involved. So you're looking at feedback systems. So you've got your obvious sort of stuff. And then you've got the impact of where your body is at that time, that can also impact, and that feedback system. 

So, because it's involving the hypothalamus-pituitary-ovarian axis, we've got to look at stress. So that plays a role because it can affect the hypothalamus. So the hypothalamus releases something called the gonadotropin-releasing hormone. And that then triggers the pituitary to release the gonadotropins which are your follicle-stimulating hormone and the luteinizing hormone.  
And so, that's more from a brain perspective. Then you've got the ovaries. Now the ovaries have got granulosa cells that are producing estrogen and they've got, yeah, the thicker cells that are producing androgens. And you've got obviously your follicle and the egg inside the follicle.  
So there are different parts to this. And this is where, you know, people will start to say, "Oh, you know, your egg reserve is running low." And they will put it to, you know, that, you know, this person might be becoming infertile and therefore definitely can't have a baby. And that's not true. 

So it's more about, you know, setting up that you might see that you start ovulating or say, we're trying to release an egg and a whole bunch of your follicles are empty. So that tends to happen as you get a bit older. So, instead of being able to fall pregnant every cycle as though, you know, you were much younger, it might be every six months you might actually release an egg. You know, that sort of, stuff. So the shells they could be empty. Eggs in shells, right? 
But what happens is inside the follicle you have a protein, a couple of proteins called inhibin A and inhibin B. And they're there to keep the follicle-stimulating hormone down. That's their main purpose. So as your reserves are becoming less, you'll see that you'll have less inhibin A and inhibin B. So, all of a sudden, you don't have as much control over the follicle-stimulating hormone. So it's actually related to the number of follicles because you've got less production of these inhibin A and inhibin B. 
Andrew: And this is measured in serum?  
Elizabeth: Yeah, you can do that. So, it's more about looking, you know, there's that FSH rising because it's out of control or starts to become out of control. But you've also got other hormones that can help there. 

So you've got progesterone that actually keeps the follicle-stimulating hormone down as well. And so, our aim as praccies is really more to, one, produce better follicles, if we can. And the way we're going to do that is by increasing blood flow to the cellular function, to the follicle. Because you've got surrounding cells that have blood flow to them that then encourage more production of the inhibin A and inhibin B and all the rest. 
So, if you've got someone that's got, say for instance, a smoker, they're going to have poorer blood flow to the ovaries and in doing that, they're speeding up the process of aging. And therefore, you'll see that they'll go into menopause much more early than they would have. So we're looking at things like smoking, we're looking at things like high cholesterol. Anything that starts to choke proper blood flow to those ovaries are going to have an impact on how those ovaries function.  
So, it's not so much just an ovary is getting old. It's actually the cells that produce inhibin A, inhibin B, oestrogens, androgens are starting to be supplied very poorly with the blood that they're needing. And if they do that, the way it's actually impacting is because the gonadotropin-releasing hormone from the brain is flowing through the blood to tell the ovaries what to do. And so, if the blood flow starts to drop away you're not getting anywhere near as much of that. 

Andrew: Yeah, the signal. 

Elizabeth: Yeah, hormone. 
Andrew: What about weight gains? 
Elizabeth: So, weight gain is going up because hormones in this time, where you may have had know, as a younger person we will have certain hormones that are high and other hormones that are low. But when you're coming into perimenopausal states you've got the slow swap of that. 

So where you may have had a better thyroid function where TSH is low as a younger person, you'll start to see it start to slowly creep up in someone who's becoming perimenopausal and therefore your metabolism is slowing down. So the thyroid is one area that you want to look at and maybe help tone thyroid up again. You know, get some blood work on that.  
The other thing is insulin where it used to be kept really low starts to become higher. So that's the other one that's sort of, swapping. So we want to look at foods that are triggering insulin release, you want to look at the insulin receptors and so forth. So, very low GI diets will help so that you're not constantly having this high demand for insulin.  
And then where you've had low hormones like follicle-stimulating hormone, all of sudden, they start to rise. Where you've had high oestrogens, they start to drop. So you're getting this swap over. And so, for us, it's more about making sure that...and you need to do it really, for fantastic results, before postmenopausal states. 

Andrew: Right. 

Elizabeth: That's why we want to step in early. When someone comes to us and they're in early 40s, we should already be preparing them for menopause years before they might actually get it, which is the average age is 51 and 4 months. 
Andrew: Are we really seeing the effects? I know that we're talking about a natural transition. I get that. But are we seeing the effects in our modern day ‘standard Australian society’ with stressful lifestyles, chronic pressures? 

Elizabeth: Oh, 100%

Andrew: Are we seeing the effects of the big bad daddy which is, you know, like ACTH production or chronic ACTH production? Is that the controller or the thing that we should be measuring to look for clues here? 
Elizabeth: I tend to sort of go by a lot of the clinical symptoms. Because we've got all these buffers and you know, things, in the blood that... 
Andrew: Diurnal variation. 
Elizabeth: Yeah, of course. You know, ... 
Andrew: What about Cortisol though?  
Elizabeth: That was my main thing. So, for me, it's more about looking at, if can measure cortisol if you want, but it's just somebody’s, you know, using saliva tests and stuff like that over a 24-hour period... 
Andrew: Do you prefer one or the other? Do you get meaningful stuff out of the serum rather than saliva.  
Elizabeth: Yeah, I usually get saliva, actually. That's the test that, yeah, normally I will say. But it's sort of becomes very obvious. What I find with a lot of clinical stuff is on that particular day that they're testing or week, they could be fine. They could be absolutely fine. 

Andrew: Yeah, yeah. 

Elizabeth: But if you're looking at times of weakness in a cycle as well. So where are they going to feel more stressed. So maybe in the end of the luteal phase or something like that, that might be a bit of time. Or in a stressful time. 
So you're looking at their mental state. How well do they cope with stressors? You know, looking at strategies. It's not just, sort of, dosing up. You're trying to do everything with them so that might be a time that you might suggest a counselor if they’re… because it's going to have a bigger impact on their body. So it's like their resilience is dropping in this state. 
Andrew: Yeah, and you want to be measuring that resilience at its lowest ebb rather than going, "Oh, everything's fine." So that's a good little clinical pearl to actually ask the patient to do the test. If you're going to do like a full salivary-cortisol test to see the drop of the day to actually do it on...pick a bad day. 
Elizabeth: Pick a bad day. 
Andrew: Yeah. 
Elizabeth: Pick a bad day. And even then I would say, you know, the main thing that I look at is if they're eating loads of sugar, say, for instance. And they might do that, you know, for a week in their whole cycle. That's going to be their weaker time as well. So the sugar is triggering cortisol responses and so on and so forth. So, as soon as cortisol is sort of increased, insulin is going to increase. 

Andrew: Yeah. 

Elizabeth. And so, you know, you're going to see that all thrown. But if that's happening around their ovulation, their ovulation will be retarded as a result. And so they're going to have this impact where that will pull back. 
So when you're looking at what we can do, what's really imperative that we want to look at is; increasing muscle mass. So that's absolutely crucial. 

Andrew: Yep. 

Elizabeth: Because that's going to play as a buffer to their insulin and their sugars. But it’s… start really encouraging women to start, you know, building thigh muscle, backside, you know, butt muscles so that their growth hormones are increasing. We're always trying to go back to that profile where your human growth hormone’s higher, testosterone is higher, and insulin is lower.  
So if we can, sort of, encourage that. Eat better, exercise more, get your mental state, you know, really some strategies in place there so that when you are feeling stressed you go and meditate or do yoga. 

Andrew: Yep. 

Elizabeth: So I usually, normally suggest yoga, Pilates, those sorts of things in women that I know have stressful jobs.  
Andrew: That's a good little tweak, a little mental tweak I think to use muscle as a buffer in the hard times rather than, you know, we always think about fat being the storage. This is the muscle that's the buffer, for those hard times.  
Elizabeth: That's right. 
Andrew: Is there any sort of exercises that you prefer? And I've got to ask you also, you said thighs, butt. What about core? 
Elizabeth: Yeah. So it's all muscles in general because the core muscle later, especially in menopause you'll start seeing things like aches and pains will increase if you're not fit. 

So because, you know, especially in busy lifestyles, it might take them two years to get fit enough to sort of have that resilience later on. So you're definitely working on core because you want the spinal support. You want your leg support, that's really crucial. You want to make sure they're getting good calcium levels so that their bones are doing well. And vitamin D. So I would be definitely checking vitamin D levels and yeah, just making sure that they've got exercises that they can, you know, chill out with. 
But you might get someone who's quite sedentary. So in that case, you would go, "No, you need to move so that you're firing up the system." 
Andrew: I think Michael Holick said it. He said vitamin D is so cheap, so safe. Just give it. Don't test. Because it'll cost you, you know, what is it? $80 to do a test. It's going to cost you $12 or $20 to supplement for about a year at a reasonable dose that a natural health practitioner would use. Not the, you know, 100 IU or 400 IU. We're talking about 2000-3000 IU.  
And of course, there's the salient thing that vitamin D comes for free. We just need to get sun exposure in the midday sun. What is your advice with regards to patients and how able are they to change their habits to get reasonable sun exposure? 
Elizabeth: I'll often say to patients, you know, I want the sunlight in their eyes in the morning to raise their Serotonin. So that's one thing. So, you know, get 10-15 minutes there. But at the same time, if they, you know, they're in the privacy of their yard or whatever, to lift their shirt up. Get sun on areas that don't normally get exposed because you're going to absorb your vitamin D much better that way. And then, yes, start to get your 15 minutes a day of sun, but if you keep… you know, it's not just about in the sun. It's about exposing skin that actually can absorb it much better. 
And then also to take into account, so if a patient comes to you and they’re of Asian background or they've got, you know, African background, a European olive skin, you know they're going to be low in D. There's a very, very high chance they're going to be low. Because they're made to be in the sun. So their sun exposure is supposed to be quite high compared to someone who's, you know, obviously very fair. So that's a real given obvious little thing as well, yeah. 
Andrew: I'll put the little point in there. Obviously, we're talking about safe sun exposure. We're not talking about burning your bare white butt in the midday sun causing an increase in skin cancer. 
Elizabeth: Yeah, exactly. 
Andrew: So, Vitamin D and calcium. What else? You know, like there's so many supplements that are thrown around but we're talking about patient care. And I think we've got to be really judicious when we're talking about this, you know, because there's so many things out there, "Oh, just use this." 

Elizabeth: Oh, of course. 

Andrew: What should a practitioner be looking at to actually guide their supplementation if they're going to go down that route. Or their treatment care or their treatment plan I should say? 
Elizabeth: The thing that I do straight off the mark is always go for the liver. Because the liver is so involved in the homeostasis of hormones and hormone feedback. And it might be that either that person has never done like a good liver turnover. And also, looking at, you know, what not to have. But I would be going for definitely liver, definitely sugar and glucose support-type of scenario. 
And then you're looking at their cycles and what may support that cycle. So if, for instance, they're in need of phytoestrogens, then you’d need to use phytoestrogens. So that at least they can just have that little bit longer of having their cycle. So the aim is to… you want to increase progesterone in the luteal phase. When you increase progesterone, so they should be having at least a 13 to14 day luteal phase. In doing that you actually keep the inhibin under control. So we're trying to do that as long as we can.  
So we're looking at trying to encourage the blood flow. Obviously, antioxidants because it will help with how our ovaries function. Vitamin C is really important for that. Zinc very important for that. So you're looking at nutrients that the ovaries love and encourage, and then you're looking at feedback systems. They're the main things I would be looking at. 
Andrew: So just looking at that feedback system, those feedback systems. I've got this picture in my mind about this zig-zag line, the perimenopause. You know, when things go awry and your body doesn't know whether it's given up or whether it's still in action. 

Can you track the sort of the more, dare I say, the word graceful curve, you know, more curvy sort of thing rather than that erratic up and down zig-zag of hormones? Can you do that with phytoestrogens and what's the safety aspects of phytoestrogens? You know, some people have said, "Oh, they're oestrogens. They're dangerous in breast cancer," and things like that. What's the real deal? 
Elizabeth: So, I tend to steer away from soy products. So that will be the one that I don't necessarily go for. But things like Vitex, Black Cohosh is a great one. But again, if you're using Black Cohosh you would need to do liver function tests and make sure what's their liver like before, maybe during. Dong Quai, Red Clover, which just encourage your ovaries to produce their own oestrogens. That's what we're actually doing. You're sort of using something that is encouraging your ovaries to produce it. 
So I use a lot of blood work. So I will get blood tests on day two or three of a patient cycle. We're looking for follicle-stimulating hormone. The luteinizing hormone in oestrogen. And then, if they're all in order, then you're fine. And then, you would, you know, you don't necessarily have to use anything but you would govern more other aspects that can have an impact. And that would be mainly stress, and sugar, and poor lifestyle choices. Alcohol is a big one, especially in the second half of the cycle, the luteal phase. Because..

Andrew: Ahh.

Elizabeth: Definitely. Because what's happening here is you're going to encourage the shortening. Because you're going to throw...especially red wines, etc. They're very oestrogen-encouraging. And so you're going to encourage the height of oestrogen, shorten the length of progesterone, inhibin then gets altered and therefore FSH starts going up. 
So that's where we, you know, you'll often see alcohol will have a direct impact with hot flushes. 

Andrew: Right. 

Elizabeth: You know, patients will say to me, "Oh, I was doing really well and I started getting all these hot flushes." And I'll say, "Did you have, you know, a whole heap of alcohol?" And they'll go, "Oh, yeah, we did. Yeah, we did."  
Notice the next day because... 
Andrew: They're Australian. Yeah, we did.  
Elizabeth: Yeah, of course, we did. Because you've also got the liver impact as well as the oestrogenic impact. 
Andrew: And, of course, they're going to be feeling or they are going to be more heightened to stressful stimuli in that luteal phase so they're going to be desiring wine. 
Elizabeth: That's exactly right. Sugars are going out so they're going to desire more alcohol. 
Andrew: Okay. So how do you manage that? Like, you know, just to say "Stop" a bit hard. What do you replace it with? 
Elizabeth: So what you're doing is the cycle is never just a two-week part of a cycle. It's actually how you look after the first half of your cycle will have an impact with the second half. Because you're helping develop a follicle. So your aim is to develop that follicle really well so that, one, the inhibin is better and all the rest, and the follicle gets larger so that the cells that produce progesterone are more. And so, therefore, you have a better amount of progesterone. But what I tend to say is increase your exercise because that also increases progesterone. So that's important. Exercise does play a role. 
And then look at, you know, recovery. So if you think, "Well, I've got a birthday party and you know, obviously, I want to go and I want to have some alcohol." You know, have water in between. Have a look at making sure you're giving a break. Don't go crazy with it. And then, for the next week, you know, just really be clean living, loads of greens, you know, all that sort of stuff. Just so that, you know, you're not missing out always but you're at least recovering really well. And that's why I say the liver support. If we can use liver support it will help you get over the sort of highs and lows a lot more quickly.  
Andrew: What about cheating a little bit? We can't necessarily inhibit the absorption of alcohol because it gets absorbed out of the stomach. 

Elizabeth: That’s right, it’s all in the gut. 

Andrew: But, you know, various alcoholic beverages have got various sugar content. Do you tend to moderate that or even cheat a little bit by saying, "OK well, have some fat or some protein to slow down the absorption of the sugars if not the alcohol?" 
Elizabeth: So, well you want to do that as well as maybe using things like, yeah, lower sugar like vodkas and things like that. But yeah, whenever you want to lower any GI, you're always having with fats and proteins because it'll lower the GI. So you're doing that as well. 

But yeah, I just sort of found that if people can, sort of, take that lifestyle a little bit more seriously at this time, they will benefit for a much longer period of time. And smoking is a big one, a massive one. 
Andrew: Yeah. It's just like, it's something you could say, "No, stop... 

Elizabeth: Yeah. 

Andrew: There's no moderation in this. You need to stop smoking." 

Elizabeth: Yeah, that’s right. 

Andrew: There is no healthy level with smoking. 
Elizabeth: Yeah, there is, that's exactly right. 
Andrew: What about the research that was done? I haven't read anything on this for years. But the research that was done regarding how a woman perceives her transition through the menopause and that having measurable impact on symptomatology. Have you found that of use, about how they approach the menopause? 
Elizabeth: Now that you've that, I've just… well, I haven't read those studies but I've just seen it in my room. Definitely, some people will come to me saying, "Look, I know I'm coming up to menopause in the next five years and I want to be in my best state to do that." And so, therefore, they know there's going to be a change. They know, they've got friends, I mean, a lot of women talk about it. And, you know, there's a lot of fear around it and things like that. 
And then, yeah, it will be very much a personality thing. So you'll have someone that just goes, "Bring it on. I need to know, I don't want to be getting old overnight." And they prepare themselves. And then other people have got all this anxiety around it. Because, you know, they know that they saw their mother go through a horrible time and things like that. 

Andrew: Yeah, yeah. 

Elizabeth: But it's just, I think, if anything it should be discussed. It should be, you know, talked about in a really sensible way. It's not really something that should be feared. It just means that you need to be... I suppose if you're going to go and climb, you know, a huge mountain, you're going to prepare yourself. You're not just going to throw yourself into that situation.  
And it is it is like that. I've seen amazing women in their menopausal years, postmenopausal, fit, very healthy, very trim. But they're very disciplined and yeah, they value their health and they take it seriously. 
Andrew: It seems they're the perfect patients. I mean, the disciplined ones. Not common. 
Elizabeth: Definitely not common.  
Andrew: So when we're talking about these symptoms, like a lot of people are going to have the symptoms and go, "Oh, hell. You know, I don't like this." They're anxious, they're sleepless, they're getting hot flushes, they're getting ratty, moody. So their partners are complaining. But, you know, the impact on not just their family environment. What about work environments? They're already in there. How effective do you find natural medicine in managing these symptoms once they've occurred? Like do you find that they can be used as medicines? 
Elizabeth: Oh, definitely. I actually have found a huge benefit in this area. I've had a lot of patients come to me saying that they've used HRT, they've tried everything. Everything's just got worse, they've got no energy now. They feel like they've got chronic fatigue, they're in aches and pains. And I can get a turnaround in a lot of these patients within a month. And I'm not using HRT.  
So definitely, the herbs I have found to be amazing. But I've found them to be much more effective if we're dealing with all the other stuff at the same time. 
Andrew: I think, I hear this comment time and time again. Those people that want a drug-like approach, "Here's one tablet to do one little thing." Doesn't work in natural medicine. 
Elizabeth: No, no, it won't, 100%. 
Andrew: It just doesn't work. It's the balancing, nourishing, it's the psyche. You've got to approach it differently. 
Elizabeth: A hundred percent. And I have done that where I've seen people not have anywhere near a great result if they just said, "Oh, no. Just give me a tablet. I hate taking tablets. Just give me one thing." And I'll often tell them, "You can try it but I very rarely see this work.” Because it's multifaceted. So I'll take my patients through a lot of the science of what's going on and then they get it.  
Andrew: What's your opinion of natural progesterone, bioidentical progesterone? Which I think now that drug companies are making it, it’s not called bioidentical. It's it a biosimilar? It's this, oh no, this is the correct term now. It's the same. It's a progesterone. 
Elizabeth: Yeah. So I have used progesterone definitely in a perimenopausal phase not in a menopausal phase. So that I can keep that in... I mean, obviously, I'm using it a lot of the time because I'm trying to achieve a pregnancy. 

Andrew: Right. 

Elizabeth: And so what happens is a woman gets older, because those cells are getting fewer, they tend to, you know, crash in the last four days before their periods coming. And so if they're trying to fall pregnant, you might see that crash where they could have got a pregnancy 
So, definitely, I have and I will use it in that group. I wouldn't necessarily use it in menopausal women. Same with testosterone and things like that. I use herbs that encourage our own testosterone. We would be looking at, you know, great adrenal function for that sort of stuff. 
Andrew: I guess my issue is a philosophical one. And so it's not the issue about the compound itself as long as it's appropriately managed. It is a drug. 

Elizabeth: Oh, a hundred percent. 

Andrew: It is a hormone. And so it's not, you know, within our realms to prescribe it but to monitor it and things like that or maybe to advocate it. But my issue is that just know that it is a hormone. You are not nourishing your body. It is band-aiding the deficiency.  
Elizabeth: A hundred percent. So, exactly. So, for me, I never use anything that's ingested via the mouth. And I will tell them, "I do not want to do that because that's got to go through the liver." And so the companies have allowed for the liver effect so they've had to use much higher doses so that the liver while it's fighting it, they've ended up with a small amount that they know they've calculated to work. So only use the transdermal... 
Andrew: You can use troches though, correct? 
Elizabeth: People use troches but I haven't. I haven't suggested those. So, if anything, I mean, for a fertility scenario I will say to use pessaries. So it's only used around the ovary area or cream. So that's it. I won't use anything that's oral. 
Andrew: Many practitioners are ofay with common symptoms of anxiety of night sweats of, you know, rattiness, moodiness, fatigue. That sort of thing. Even vaginal dryness. But what about things like vaginal bleeding whether it be spotting or dysfunctional uterine bleeding or something like that? And I'll have to also ask about this question. What if a woman has had a hysterectomy for other reasons? They've got their ovaries intact but they have no way of bleeding. How do they then monitor what's going on when? 
Elizabeth: Very good question. And actually, people will say, "Oh, I've had a hysterectomy so I don't get periods." But we actually can monitor it via temperature. So that's a pretty clear one, where you can know, I'll get them to see that, you know, "Here, you've ovulated, temperatures have come up." And I definitely use temperatures in those cases because if I'm trying to balance their hormonal states, I need to know how long their luteal phase is. I want to know what's actually happening in ovulation as if they were having their period. And as soon as you balance that up, well, a lot of their symptoms disappear, they feel heaps better. Even though they can't fall pregnant again. So you're not doing temperatures for pregnancy. So that's on waking temperature basal. And then obviously, blood work. You can do a whole heap of blood work in girls like this. 
So, once I do the temperatures and I go, "Okay, now we know this is your day one or two because you can see where you're at," then go and get some blood tests on those days and we can, sort of, see as they're changing and getting better, etc. 
Andrew: And they're reasonable surrogates of what's happening hormonally because if you're looking at a target, an effect if you like. An effect on the cell. I'm just thinking about a cost-benefit here. Do you find these are reproducible, trackable? 
Elizabeth: Oh, yeah. 
Andrew: Yeah? 
Elizabeth: Hundred percent. 
Andrew: So there's something that a practitioner can advocate to a patient to do at home that's going to save them bucket loads of money and maybe do a test one every, you know, six months? 
Elizabeth: Or even looking at your urine LH testing. They can do that. So if they're, sort of, sitting there thinking, "I don't know, am I'm still ovulating or when did ovulation happen?" They can test their LH, they can see it go up, they can see it come back down again. So they can spot, "Okay, here I've got this, sort of, regular cycle. Because then I can see, you know, this isn't just..." Where it's really confusing for them is they're getting PMS symptoms so we can actually aid, but they don't know if it's PMS anymore. They think it might just be them. So, once we sort of go, "No, this is what's happening." 

Andrew: Ahh, right. 

Elizabeth: So this happens a lot with cycles actually. Like, you know, I've had patients have hives at certain times of the cycle and I've had them have all these symptoms and I'll say, "Where are you in your cycle?" And so, as we correct the cycle, the hives disappear. Because we can sort of see that's maybe where cortisol is going up. Immune systems may be put under duress and all the rest. And so, as you can control it, because as soon as you go, "Oh, it is hormone-related." As soon as we can correct the hormones all the other symptoms can disappear. 

So it's just more if you don't know it's hormone-related you might be chasing your tail going from one specialist to the next specialist. So yeah, I just found it's really helpful that way.  
Andrew: So, do you tend to use liquid herbal formulas? So, you know, I mean you've mentioned look at the thyroid and the liver, stress response and then some phytoestrogenic-type herbs to manage that sort of symptomatology component. Do you tend to use exclusively liquid herbs? 
Elizabeth: No, I’ll use a combination.  
Andrew: Do you tend to employ nutrients? Or it's...? 
Elizabeth: I use a combination. So it just depends on what I'm sort of seeing. So if someone's having a thyroid issue in this period of time I'll make sure that they test their iodine. And a lot of them are coming up low in iodine. So we want to support the iodine so that at least the thyroid can produce the T4 much better, etc. 
So you're looking at certain nutrients that are missing there. I will never use just...I mean, I very rarely would just use liquids. The liquids I use is fine-tuning. So I tend to go, "No, the nutrients are more you're stable… I'm trying to get some really good stability with the way your organs... I'm supporting the organ there." And then I don't tend to give liquids on my first visit with somebody either. I'll sort of go, "Look, I want you to see what this stuff is doing first," the changes, and then as they come back and maybe half the symptoms have disappeared, then I'll fine-tune with liquids after that. 
Andrew: And how do you go with compliance? Taste is a real big issue. How do you... Do you find that this is the art of your practice is trying to make something that's at least not as bad as flavours as some. 
Elizabeth: Yeah. I mean, what I have found is that if the problem is bad enough, if they're suffering enough, I tend to see compliance is better. 

So, I'll have patients say to me, "Oh, no, don't give me the liquids. That was awful last time. Don't do that." And I'll go, "Okay, that's fine but you might have to take five tablets now.” 

Andrew: Yeah. 

Elizabeth: “And I'm happy for you to do that." And they'll go, "Oh, that's okay." Some of them will go, "That's fine. I'll have the five tablets." Other people go, "Oh, no, it's all right. Give me the liquid. I'd rather take liquid than an extra five tablets." You know, that sort of thing? 

So, you know, it's person to person. If I find that something, you know, tastes really bad you might use some glycerol or something like that to make it a little bit better or I might... 
Andrew: Try. 
Elizabeth: Yeah, yeah, yeah. Or I might, I might, you know, use a particular...say, for instance licorice or something like that that will help… 
Andrew: Yeah, licorice and ginger and the herb flavoring. 
Elizabeth: Yeah, exactly, that will flavour it up a little bit. 

But yeah, I don't tend to see it as a huge issue actually, just because I'm usually their last resort. You know, they've tried everything. You know, or they might have a cancer history in the family, or a strong cancer history and they don't wanna use HRT. So they're willing to do whatever and they're fine with taking the liquids. 
Andrew: What about Chinese herbs systems of medicine, you know, the Western versus the Eastern. The Chinese, the TCM framework, like it's complex. But even if we arrogantly use some of those, because they are like, heroic. 
Elizabeth: Oh yeah, yeah. I've used a lot of Chinese medicine. 
Andrew: Yeah, tell me about that. 
Elizabeth: A lot of Chinese medicine. So in this context for perimenopause, yeah. I mean, Dong Quai is a fantastic herb or this particular thing. 

Dong Quai is oestrogenic. So it has that but it's also working on liver, it's also an autoimmune suppressor and things like that. But it works really well in this particular case because it's helping blood flow to the ovaries. So that particular thing. But I'll use, you know, Ayurvedic, I'll use all sorts of herbs. You know, Shatavari is a fantastic one as well in this particular case. 
But yeah, I've done quite a bit of Chinese medicine so I've learned to speak their language a little bit. So I know what they're saying when, you know, they're talking a particular way. But yeah, they've got fantastic herbs that are all mixtures. I use quite a bit of that sort of stuff. 
Andrew: Yeah, Minor Bupleurum. I mean Peony and Licorice. For you know, I think there was polycystic. It's just famous for getting results. But when you're talking about, you know, the liver involvement and those inflammatory aspects, Minor Bupleurum was just this, "Oh, my goodness. You know, I use it and it has changed." 

Elizabeth: Yeah, yeah, yeah. 

Andrew: But I really think we need to investigate. Do you have to become a TCM practitioner? Probably not. 
Elizabeth: No.  
Andrew: But should you investigate that formally, probably, you know.?  
Elizabeth: Yeah, yeah, 100%. 
Andrew: So okay. Where's your experience with issues of safety with this? You know you hear the TGA banging on about. And they usually are illegal internet imports. You know, people selling Chinese herbal formulas laced with, you know, well, there’s drugs, Sildenafil or something. 

What's your issue with safety versus efficacy and reputation? Do you find that we're pretty-well monitored in Australia with the herbs that we have here? 
Elizabeth: The Chinese herbal mixtures that I'm using are TGA-approved and stuff like that. So, I wouldn't use anything other than something that's been approved.  
Andrew: Yeah, I think that's a big danger. And for our listeners overseas, that is your concern. You know... 
Elizabeth: Oh a hundred percent. Well, the way they're fertilising things and stuff. Yeah, you know, there's no way that I would use just anything. 
Andrew: So we mentioned irregular bleeding. Let's go into that because that's a real red, or could be a red flag. How do you monitor that? When do you get them checked out and refer out? When do you take control? 
Elizabeth: So you're wanting to look at their pregnancy history. So you want to sort of see how many children they've have had as well. Because if they haven't had any the chances of them having things like endometriosis is very high. And then fibroids can be quite high as we get a bit older. Because what you're looking at is high oestrogen to progesterone ratio. And if the oestrogens are going up higher and higher you're going to encourage growths, you're going to encourage polyps, you're going to encourage fibroids. And they will bring with them spotting, short luteal phases, etc. So, definitely want to be investigating.  
If a woman has menopaused and actually bleeds, you need to get her to a doctor. That is very important. We need to check out what's going on there. That could be sinister. So, you definitely need to do that. 

But spotting before a period is a red flag for progesterone issues. So you want to be looking at that. Spotting mid-cycle and things like that, you're looking at fibroids, you're looking at maybe endo or polyps. So yeah, you definitely need a really good gyno working with you in this area so that you're know, like, I love that. Like we go back and forth. They're happy to do investigations that I suggest, they'll do bloodwork that, you know, we may need and it just helps me use natural sort of medicines to help. 
Andrew: You're an expert. You've done your masters in Reproductive Medicine. What would you say to practices who haven't done that about dialoguing with doctors, specialists?  
Elizabeth: It's more that if you haven't done much as far as education goes and you've done say naturopathy or herbal medicine and someone's coming, presenting with quite difficult symptoms and you're out of your depth, you need to refer on. It's just so complicated. And you could actually encourage the wrong thing. So if you're thinking, "Oh no, oestrogens is lower in, you know, the..." 
Andrew: Because that's what the book said.  
Elizabeth: Yeah, the oestrogens are low in this time. Well, actually, that's not necessarily the case. Oestrogens could actually be quite high but the person's not ovulating. 

So you have to know how to actually manipulate what you're looking for and all the rest. So, I definitely would pass on, or go get more education. If you get more education you're going to understand's so fine-tuned. We're talking like day-to-day movements in that cycle if you really want to help that patient perfect everything. So you've got to know exactly how to look and what to look for. 
Andrew: And of course, we never covered acupuncture. What do you find the utility of acupuncture is?  
Elizabeth: So, your acupuncture is great in women that are really struggling to ovulate especially if you're out of your depth. So if you're sort of thinking, "Oh, God, I don't know. Why isn't she ovulating?" Often, if you use acupuncture and they sort of get blood flow working better to the ovaries in doing that. So they will put needles around their ovaries and things like that. That can help. It can help with mental states. So stress levels and things like that. Aches and pains. 

But the main thing I'm using acupuncture for is when I see that… it's like there's a delay, I need something to just sort of push it through. And I work closely with acupuncturists who know, that they're not giving herbs or anything, they're just going to work with me, etc. with what I'm needing, yeah.  
Andrew: And you said stress management. What about a manual therapy, like, for instance, you know, therapeutic massage for stress management? Do you find that that has a measurable effect? 
Elizabeth: Anything, I think, that where you really feel relaxed or you had that release of stress is going to be really, really helpful. But some people might find a massage really not a great experience. So you've got to sit there and think, "I need…" One, it starts with loving yourself. You have to put enough time. So, a lot of people are mums, they're busy, they're running around. So you've really got to go through the psyche there of where that person is at.  
So if they're sitting, they're thinking, "I know what's right. I know I want to take these things but I just can't find the time," then you would be looking at that. You've really got to zero in on that. Because that's where your first hurdle is. And then after that, you're looking at, "Okay, now, what are you doing for exercise? What are you doing for eating well? You know, what are you doing as far as taking time out to just spoil yourself?" Laughter, friends, you know, community. And that's why I always sit there and go back to, "If you weren't in our society now, if you were in nature, what would you be doing?" And we've really got to try and mimic that even more in this scenario. You know, you would have had friends, you would have talked, you would have had children running around. It would have been a lot of community around you, you know. 
Andrew: I've got to say, men would be stuffed if it was menopause. Because we don't talk, we don’t communicate. 
Elizabeth: I agree. I agree. 
Andrew: Whereas, women can share. They go around and they have a natter and they go, "Oh, my goodness." But they actually connect. 
Elizabeth: Yeah. 
Andrew: Elizabeth, I can't thank you enough, seriously. There's so many avenues we could go down. And I think I'm going to have to get you back to look at post-menopausal care because that's another arena that we need to look at. 
Elizabeth: It is.  
Andrew: So, I look forward to you joining us on FX Medicine with that. But thank you so much for taking us through the perimenopause today. 
Elizabeth: Pleasure. Pleasure, Andrew. 
Andrew: This is FX Medicine and I'm Andrew Whitfield-Cook. 

Additional Resources

Elizabeth Mucci
Life on the Inside


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FX Medicine Podcast
FX Medicine is at the forefront of ensuring functional and integrative medicine gains the recognition it deserves and ultimately establishes itself as an integral part of standard medical practice. Hosted by Dr Adrian Lopresti, Dr Michelle Woolhouse, Dr Damian Kristof and Emma Sutherland, our podcasts are designed to promote research and evidence-based therapeutic practises, acting as a progressive force for change and improvement in patient health and wellbeing.