Dr. Cabeca is a wealth of information and inspiration when it comes to women’s health. I am delighted to share my conversation with her this month, in which you’ll learn about:
- How Dr. Cabeca transitioned from performing multiple surgeries per week, to only needing to recommend a handful per year with a functional medicine approach
- The best lab tests and specimens for hormone assessment
- The importance of liquid chromatography mass spectrometry for serum free testosterone measures
- Factors to be aware of that can confound hormone testing results
- Estrogen metabolites and the importance of methylation assessment
- The sweet spot of keto-alkaline status for sex hormone balance, cortisol management, mental clarity, insulin sensitivity and weight loss (target pH of 7, and some ketones 3+ days per week)
- The benefits of vaginal testosterone and DHEA for tissue repair and incontinence
- Watching out for behavior change with testosterone to ensure appropriate dosing and saving marriages!
- Addressing vaginal dryness with safe oils and DHEA, diet and lifestyle
Anna Cabeca, DO, FACOG
Dr. Anna Cabeca is an Emory University trained and board certified Gynecologist and Obstetrician. In addition, she is board certified in Anti-Aging and Regenerative Medicine and an expert in Functional Medicine and Women’s Health. She specializes in bio-identical hormone replacement therapy and natural alternatives, successful menopause and age management medicine.
In addition to her private practice, Dr. Cabeca is a frequent national and international speaker on restorative and women’s health issues. She serves a consultant and trainer for other physicians in Bio-Identical Hormone Replacement Therapy and Functional Medicine Principles.
Dr. Cabeca is the co-creator of the Sexy Younger You telesummit and the creator of the highly acclaimed virtual transformational programs: WomensRestorativeHealth.com and SexualCPR.com.
Dr. Cabeca is passionate about supporting women in creating health and hormone balance for themselves as well as many generations to come.
- Website: www.cabecahealth.com
- Email: gims@cabecahealth.com
- Get 10% off Julva™, Mighty Maca™ and PurabalancePPR Cream: http://drannacabeca.com/drkara/
Podcast sponsored by Designs For Health
Designs for Health is a professional brand, offered exclusively to health care professionals and their patients through referral. By providing comprehensive support through our extensive line of nutritional products, our research and education division, and our practice development services, we are able to maximize the potential for successful clinical health outcomes.
Dr. Fitzgerald:
Hi everybody, welcome to New Frontiers in Functional Medicine. I am your host, Dr. Kara Fitzgerald. Today, I am thrilled, honored, excited to be talking to Dr. Anna Cabeca. She is a longtime friend and colleague. In fact, I think I’ve known you, Anna, for really, basically, my entire career I’ve been connecting with you. I just love the work you’re doing, so let me tell New Frontiers about you. You are an Emory-trained, board-certified gynecologist and obstetrician. In addition, Dr. Cabeca is board certified in anti-aging and regenerative medicine and an expert in functional medicine and women’s health. She specializes in bio-identical hormone replacement therapy and natural alternatives, successful menopause and age management medicine.
In addition to her private practice, Dr. Cabeca is a frequent national and international speaker on restorative and women’s health issues. She serves as a consultant and trainer for other physicians in bio-identical hormone replacement therapy and functional medicine principles. Dr. Cabeca is the co-creator of the Sexy Younger You telesummit and the creator of the highly acclaimed virtual transformation programs womensrestorativehealth.com and sexualCPR.com. Dr. Cabeca is passionate about supporting women in creating health and hormone balance for themselves as well as for many generations to come. Dr. Cabeca, it’s just a warm welcome to New Frontiers. I am just thrilled to have you here today.
Dr. Cabeca:
Well, I am thrilled to be here, Kara, it’s been wonderful to watch you in your career and your development and what you’ve been doing in this world. I think you are amazing.
Dr. Fitzgerald:
Yea, likewise. Likewise, I mean, you’re a font of knowledge in the women’s health arena and I’m just so excited to get to do a concentrated brain picking of Dr. Cabeca today. I really want to jump right in and start mining those pearls from you. Let’s talk about the standard of care for women’s health, and specifically we’re looking at perimenopause and menopausal women, although definitely chime in and around premenopausal women as well and the various hormone changes that we undergo from ages 30 and up. Talk to me about standard of care. I mean, you’ve got a very traditional, solid training and you’ve transitioned into functional medicine full on, so what are you seeing there and what prompted your shift?
Dr. Cabeca:
Yeah, it’s very exciting, actually, as I kind of developed into my career and integrated the concepts from standard gynecology and obstetrics, but also I went to Emory, an allopathic institution, as an osteopathic physician with a very holistic mindset. Functional medicine was the next step, and then working in sexual health and bio-identical hormones was key because I came to practice on a small island in southeast Georgia, as a national health service course scholar. I was the end-all, and I had to be very forceful in what I had to develop for my clients. What I noticed is that what we were doing in our clinical practice was just pretty much band-aiding to wait for the next sequence of events to evolve.
That was really frustrating. In many cases, unacceptable. Many clients couldn’t afford surgeries, couldn’t afford many expensive prescription drugs, so I would like to kind of give the scenario of the typical client coming in as she’s going through early perimenopausal transition or early hormone changes, and really what our patients are dealing with today. The clients that come to our functional medicine practice have maybe already received part or some of this, these concepts of standard care, so I’d love to talk through that, and then how my practice evolved to kind of not need this.
Dr. Fitzgerald:
Yes, please do.
Dr. Cabeca:
Okay, great. Typically, we’re going to start see hormonal changes in women around the age of the 30s, and I’m kind of starting to laugh, because the statistic struck me right now that 1 in 3 of us, 1 in 4, 1 in 3, it was 1 in 4 by 2010, are in the menopausal, perimenopausal age range. 1 in 3 probably more likely 1 in 3, 1 in 4 of us are in the perimenopausal age group. I’m like, “We need to get our moods stable, for the good of society, right? It will make a difference.” Typically around age 35, our hormones are going to start to shift. Clients came in regularly complaining of mood swings, irritability, PMS symptoms, right? We know that as their doctor, because of these PMS symptoms, what we have to do to treat them is to give them an SSRI, right? Just pile on the Prozac, now called Seraphim or whatever new medication is in your drug sampling cabinet.
Let’s give that to them daily, or just the last two weeks of their cycle, into the luteal phase, from the day of ovulation to the day of first bleeding, which we call Cycle Day 1. That’s a standard of care philosophy, but the client will typically come back having irregular periods, ovarian cysts, more painful cycles, heavier periods and continued symptoms of PMS. We will then prescribe birth control pills. Let’s just knock this down, even if you’ve had your tubes tied, this may be the answer to your problem, so let’s just knock out your HPAT access communication system altogether and let’s just suppress the ovaries and kind of get that stable.
Certainly, there are benefits to that, kind of get your feet on the ground, etc., but lo and behold, uterine fibroids developed, you continue to have your regular breakthrough bleeding, it’s uncomfortable, you just know that you are alien to your own body, and so the next answer coming in would be, “Okay, well, we can do and endometrial ablation. We can do a D&C, we can then proceed with a hysterectomy and since you are over age 40, let’s go ahead and take the ovaries out so you don’t have the risk of ovarian cancer.” As I dug into this, research shows that our 65 years old plus ovaries are still producing hormones and are still hugely involved in the communication system, as well as if we maintain our ovaries, we have a reduced risk of cardiovascular disease. The research is out there.
So, what happens? We’ve treated this client as a gynecologist and really loving our patients and wanting to do what’s best for them and using what’s in our toolbox with our armamentarium of our prescription pad and our surgical knife, and our client is still struggling. She has a decreased libido, is really having difficulty in her marriage, she is continuing with fatigue, she has short-term memory loss and she doesn’t even remember the last time she had sex, and that’s not because of the short term memory loss. Then, she has lack of concentration, so sensate focus is out, so sex life is really diminishing. She may experience thin drying skin and the other things that are going on our aches and pains and sleep disturbances and that continues. It doesn’t bode well for the marriage and her next appointment is maybe for a divorce attorney and a psychiatrist.
It’s sad to say, but it’s true, and I’ve seen this happen in my practice as well as in clients that I’ve seen come in looking for, finally, an alternative way of care. Early on, I just started understanding and researching, “Okay, what can I do?” I started balancing with bio-identical progesterone when patients came into me, they would get a series of comprehensive labs and I would start them on my detox program, get them on the modified elimination diet, 21-day detox, run some labs, put some bio-identical progesterone onto them and some key nutrients as I start to figure out, this is a decade and a half ago, that all vitamins are not created equal. I was really surprised.
I started using nutrients, and the client would come back in six weeks saying, “Hey, gosh, my symptoms are better. I don’t even have symptoms. I couldn’t even tell my period was coming,” and I was shocked because I learned that. Do you know what I mean?
Dr. Fitzgerald:
Right. Listen, I just want to back up and just kind of underscore some of the amazing things you’ve just said. I know you’re on an island in Georgia. I was in Atlanta for my post doctorate training, and I know that’s when we connected some years ago now. You’re the GYN on the island. You’re serving this population and the buck stops with you. You are using really sophisticated, totally standard of care medicine with this population, because I know you want to do right by your patients, and you are really right, so you’re drilling down into the literature and you are using surgical interventions. You were using the latest drug interventions and you outlined the progression of what would happen with these top standard of care interventions, and each one you just went through how they would fail, and your patients would come back with this additional evolution of symptomatology, and then you would go to this and that and this other.
You are witnessing, as you are the GYN on this island, that your patients were just suffering, and then their lives would suffer and their relationships would suffer. I would imagine that must’ve been an extremely heart-breaking process for you, as you’re the healer out there. That prompted you, obviously, on your own journey, to begin to drill down into what the alternatives were. I know that’s where we are now and where you’ll pick up on this really interesting story, but you just started to discover years ago that a little bit of bio-identical progesterone, a little bit of detox, went a long way. Pick up from there, because it’s really a powerful personal story, your evolution as a healer, and discovering that. I wanted to just underscore it. Then what happened as you were doing this? Go ahead.
Dr. Cabeca:
The parallel vein, treating women with sexual health issues what’s happening at the same way. In the concept of perimenopause, right, in the menopausal symptoms, I’ll tell you, honestly, I went from operating 2 to 3 times a week, to eventually referring out 1 to 3 surgeries per year. Okay? So it’s a difference. I definitely think I did go pray and believe that I did a lot of good with the surgical interventions, but as I worked at addressing functional root causes, I no longer needed to carry my high surgical, I mean, I wasn’t operating enough to justify my surgical malpractice insurance, so I ended up referring out 2 to 3 surgeries per year. I mean, that just kind of transitioned. Often, it was because an endometrial cancer was diagnosed at the time of first visit, something like that was where I couldn’t get in, but I would still work with them pre-operatively to have the best post-operative outcome.
That kind of evolved, but at the same time, Kara, I have to tell you inmy evolution, there certainly was a personal evolution and a professional evolution, but another reign of my professional evolution that developed my professional expertise in sexual health was in my first, seriously, my first month of practice down here in Southeast Georgia, I had a 64-year-old woman who had come in with a history of ductal carcinoma in situ of the right breast, which was diagnosed at age 58, so 5 years prior. She was treated at Emory University and was at this dynamic, 5 foot 10, 155 pounds white-haired tall, thin woman who was a CEO of a biotech forum saying, “I’ve waited three months for my appointment with you. you. I knew you were coming and you were from Emory. I have lost my sex drive, I’ve had this DCIS and I have terrible vaginal dryness. My sex life is very important to me. I’m a woman of the 60s and my relationship is suffering. Doctor, what are you going to do?”
Dr. Fitzgerald:
No pressure.
Dr. Cabeca:
Yeah. Yeah, exactly. I was like, “Okay, let me look at my doctor’s bag, what do I have for this woman? I’m sure to have something.” I looked and I looked and I’m like, “Okay, Emery said that she can’t use any hormones. What’s going on with them?” Then I looked at the research. I was a researcher for the Navy in hyperbaric medicine and exercise physiology before I went to medical school, so I loved the research. I looked deeply into it and I started recognizing, “Well, the remote research shows that vaginal estrogen has a beneficial effect in clients, even if they had breast cancer.” Not saying the DCIS, noting the difference. She only had DCIS, right?
Dr. Fitzgerald:
Right.
Dr. Cabeca:
Vaginal estrogen has some benefits, decreases morbidity and mortality in clients with a history of breast cancer. Then, what about testosterone? What about progesterone? Bio-identical progesterone, what’s the mechanism of action? Lo and behold, it was funny, though, Kara, I have to tell you that I remember that I did her blood work. I’m like, “Okay, well let me look at her labs and see what her hormone levels are.” Estrogen was less than 20, progesterone was less than 1, testosterone was 0 according to the labs. This was in 1999, and they were all read as normal.
Dr. Fitzgerald:
Oh my gosh, yeah, right, right, right. The reference ranges are horrific.
Dr. Cabeca:
Right. Right. Testosterone 0 normal? Okay, I cannot trust this. That dug me on another aspect. Okay, well what really is, forget normal, let’s look at optimal, right? I treated her with estrogen vaginal cream, I treated her with androgen therapy, testosterone sublingual, and I used a progesterone cream on her and what I saw her over the decade as I treated her was improved bone mineral density, improved sex life, restoration of her sense of focus and authority and self, where often I hear women complain, especially that low androgen symptoms of, “I’ve lost my edge.” At 74, she was still lobbying on Capitol Hill, skiing. Last time I saw her, before I retired my clinical medical practice, she had was with a crutch and I’m like, “What happened?” She goes, “Well, I was skiing some black slopes in Colorado.” I’m like, “Okay. Well, that’s okay.” She completely recovered from that, but those are things I saw, and that was hugely empowering.
Also, case after case of that enabled me to help others in the sexual health and recognizing, too, that we can’t just heal the body. We have to heal, especially working as a gynecologist in sexual health and as providers, we have to heal not just the individual physically, we have to heal the individual emotionally and relationally. It’s nice that we can get them physically better, but if we don’t heal the relationship, that’s why I treat the client as a team, a partner, that makes a really big difference. I learned that, and that’s why I created the Sexual CPR program, to really help clients develop that repertoire and improve their levels of intimacy, not just physiology. There is several layers when it comes to sexual health that are so vitally important to be addressing.
Dr. Fitzgerald:
You’re really looking at the mind/body connection in that program. That’s wonderful. Is that an ongoing program? We’ll definitely have the links that I mentioned in your bio, and anything else that you want to connect people to on the web page for our podcast, but that’s ongoing, so we could refer patients to it that we could …
Dr. Cabeca:
Yeah, yeah, absolutely. There’s a complimentary, “Help, Doctor, my sex drive has no pulse!” Introductory webinar that’s about an hour and a half long, and that’s free for clients. Then, the Sexual CPR program is a 7-week series. A lot of good information, that. It’s ongoing, it’s evergreen.
Dr. Fitzgerald:
Oh, that’s wonderful. Listen, just going back to, I know clinicians are going to be wondering, I’m wondering. With regard to, and I think I’m jumping ahead a little bit, but you’ve talked about labs and you’ve talked about the horrifically huge reference ranges that are virtually useless, and I’m curious now what you’re using to assess hormones. What labs do you consider to be reliable?
Dr. Cabeca:
Well, you know, I have had the pendulum swing. I have done thousands of dollar’s worth of testing on the clients, and then I worked on minimizing it for when we absolutely need it. As a clinician, there’s the art of medicine you really get in tune, 90% of our diagnosis is based on our history and physical, right? The other 10% may include labs. 90% is a huge amount, so we can learn a lot through questionnaires. I’ve developed some questionnaires, and just in interaction you start to identify the signs and symptoms and be able to evaluate them. I would say that the “eyes don’t see what the mind don’t know”, that’s an Emory saying, actually. Learning what’s going on, but I had to go through the whole REM and I think we met way back when I was consulting at Metametrix.
What I wanted was a women’s health profile, which I created, that incorporated many of the functional tests that I really wanted to see in pre-pregnancy and menopause, etc. That was a huge eye-opener for me, but again, it was very expensive. Not everyone could do it. I have tested every body fluid there is from an individual. I’ve looked at saliva, I’ve looked at urine, I’ve looked at vaginal fluids, stool cultures and all of these. Blood, serum, and there is a difference. I’ve actually lectured on the differences in hormone testing in blood, serum and saliva. There are different times and reasons to use the different body fluids, but what I’ve come to do in my coaching kind of practice is look at initially, baseline serum labs, I get those results really, really quick through that and questionnaires.
I look at, the key labs that I really want to look at, it won’t surprise you, but may surprise other people, is the HS CRP, the Highly Sensitive C-Reactive Protein. It is hemoglobin A1C, is Vitamin D25 hydroxy and DHEAS. When we’re looking in the serum, we’re looking at DHEA sulfate. When we’re looking in the saliva, we’re looking at straight DHEA. Those are for a baseline, and then we’ll add on hormone panels, which will include estradiol, total estrogens, progesterone, free and total testosterone, and that I like via LCMS. Now, there are different ways that your lab may test, but liquid chromatography mass spectrometry for your free testosterone levels is really important, noting that if a client is on transdermal gels or creams, you’re not going to pick that up with LCMS in the blood. It’s that specific. It only will look at endogenous levels or if you’re being injected with testosterone.
Dr. Fitzgerald:
That’s really helpful, thank you.
Dr. Cabeca:
And then DHEAS and sex-hormone binding globulin. I want to watch that over time. The first time I do it, it may not … The same thing, labs are done at a certain instance in time, so I’ll touch on when I want to look at labs. That’s really, really important, especially when we’re talking about hormones. Additional hormonal labs will include I said DHEAS. We’ll do a morning cortisol. Also, your TSH, free T3, free T4, thyroid antibodies, reverse T3. You want to look at the comprehensive thyroid. I’ll look at a ferritin, I’ll look at IgF-1, and so that’s really comprehensive, but if I had to get four tests for any client, those would be the first four I mentioned. Then then when we test. In menstruating women, it’s really important, if were looking at ovarian function or fertility, we want to do a Cycle Day 3, estradiol, FSH, LH. Any other time during the cycle, it doesn’t tell me anything.
If a woman is on birth control, it doesn’t tell me anything. If she’s on birth control pills, let me say that. It won’t tell me anything. We cannot judge a woman’s hormones adequately if she’s on birth control pills. Menstruating women off birth control pills, I’m going to look at Day Three estradiol FSH, LH to look at ovarian reserve function, possibly and then at peak hormone levels between Cycle Day 19 to 21. Now, many of your clients are having irregular cycles and may not know, but that’s okay. Let’s just choose a day around Day 19, if we know they’re ovulating, let’s just choose a day and when we do follow-up labs, let’s do it on that same cycle day. That’s as close to apples-matching test as possible.
Also, the same time of day, before exercise, and if they’re on hormones, I always say 6 hours after their morning dose of hormones. There’s some arbitrariness in that, but you’re keeping consistent from when you’re checking, time and time again, to the best of your ability or when you’re looking at hormones, especially in women, you want to know what was going on. Men, too. Fasting, before exercise, let’s look.
Dr. Fitzgerald:
Yep, got it. Okay. Right now, I think you’ve been talking about serum basically, correct?
Dr. Cabeca:
Yeah, yeah.
Dr. Fitzgerald:
Okay, good, so for folks interested in the testosterone pearl you shared as well as all the other labs you’ve mentioned, we’re talking serum here.
Dr. Cabeca:
Serum, yeah. The reason is because I get those labs back in two to three days, right?
Dr. Fitzgerald:
Yep.
Dr. Cabeca:
Then you’re going to include your beautiful Berkeley Lipid Panel, or you’re going to include a red blood cell zinc and a red blood cell magnesium. Not serum magnesium, I don’t care what that is, really. I want to look at the red blood cell magnesium, and it’s typically low in all of us so I may or may not add that on depending on expense.
Dr. Fitzgerald:
Yeah, okay. Okay. That’s terrific. Now, let’s just, I could talk to you all day about labs. I just really appreciate this. It would be an easy rabbit hole for me to go down. Going to ask you one more question, then I want to move over talking a little bit more about what’s happening in menopause in what you do. Because, you cast a wide net, you’re using a full functional medicine approach, so I want to get to as much of what you’re doing. I want to get to botanicals, too, but my last question, are you looking these days at estrogen metabolites?
Dr. Cabeca:
Yes.
Dr. Fitzgerald:
Are you looking at SNIPs and influence of those on hormone metabolism? Can you just say a few things?
Dr. Cabeca:
Yeah, absolutely, and I think, again, you start with the basics. Get them as cleaned up as possible and then fine-tune, is what I’ve found. There are a few clients that can handle the information overload of everything at once. Believe me, I’ve done that to quite a few. What I’ve found, and from training nurse practitioners, actually, was that their approach was one step at a time and patients don’t really feel overwhelmed with that. That’s kind of like how I would intake clients, get those core labs, I have them do their detox, come back to see me in 6 weeks. Then, you go on from there, looking at urinary metabolites. Yeah, I think urinary hormone testing, like the DUTCH labs, Precision labs, what we did in functional medicine labs at Metametrix, now Genova, with the women’s health profile.
I mean, there’s such good information in that. I found that for myself and my client, especially when fine-tuning nutrients. Fine-tuning nutrients and trying to use the minimum, you know, we don’t want handfuls of supplements. We really want to work on the lifestyle, which really makes a difference. This is kind of where it started to blow my mind and change my practice, especially treating clients at menopause. I would treat, I would look at the saliva, I could look at, it depends. I could spend an hour talking about this, for sure. It goes into what works best for you in your clinical management and follow-up, but I think there’s a validity in looking at all of the ways our hormones are circulating and communicating with us.
Estrogen metabolites are key. I think we should have a 23 ME in general, but I think definitely look at methylation is huge for women. This is, again, assuming no one has had a history of breast cancer. Once there’s a history, I mean, if there’s a history or risk of breast cancer, these are mandatory. We need to know their Vitamin D level, we need to know their methylation status. We need to know on and on and on, their estrogen metabolites. We think there is value for all of that, but we’re going to see it, and this is where I came to kind of develop my Magic Menopause program that just launched, magicmenopause.com. I do it live, I’ll probably create it into an evergreen in the future, but what I worked on is that some of the things that worked when we’re really resilient in our 20s and 30s, and that really works well for men in hormones, doesn’t work well for us when we get into menopause.
I will say, I claim myself a menopause expert because I’ve now been in the menopausal time-frame three times, menopausal diagnosis. At age 39 with a premature menopausal failure, then in my mid-40s, post a very significant stress time and now at age 50, periodically popped into definitely a perimenopausal status. My clients suffer, too, 10 to 15 years perimenopause. What’s going on there, there’s a big function of stress and life circumstances that can drive our hormone levels. What happens as really our HPAT G axis is kind of switching or changing or evolving, let’s say, there are certain things we do better and certain things we don’t do better. I do want to mention that one thing we do better as women in our 50s is hold onto calories.
Dr. Fitzgerald:
Yeah, indeed.
Dr. Cabeca:
Conserve weight and carry. One of the big things that I’ve been working on is really getting clients, and this is what I did in part of my detox is getting patients alkaline first, right? We want them to, and I have them, created these little urine test strips that include pH on them and ketones so that my clients can very cheaply, for pennies a day, just check, are you alkaline, throughout the day? That’s really key, and 90% of my current group of women in Magic Menopause at the start of this program were not consistently alkaline. 90% of women who thought, too, they were doing the right thing all along, right? Not consistently alkaline with a urinary pH. Yes, there’s a lot of conversation that can evolve around this, but that’s a key point.
Then, figuring out, okay, well, what do we need to do to get into this fat-burning mode and why can’t we get there. The benefits, we know from functional medicine, just the benefits of a ketogenic diet, intermittent fasting and certainly we recommend a very holistic type of ketogenic diet. I’m like, “Okay, well, when I tried ketogenic diets and when I try to put my hormonally fragile women on ketogenic diets, we experience something I like to call keto-crazy.” Keto-crazy is not a good place to be. What do we have to do to kind of figure this out? I have my 90-year-old father living with me, suffering from kidney disease at the time, and I was like, “Okay, dad, you’ve got to be on this ketogenic diet, but I go crazy. I’ve got to figure this out.” I started checking my pH again and thinking, “Wow, I’m really acidic during this. What if I get alkaline and maintain the alkalinity with getting my body into fat burning mode and checking for urinary ketones?” Look, behold, it’s a huge evolution and in maintaining that, was able to drop 18 pounds and just have this experience of energized enlightenment.
I’m like, “Oh my gosh, this is what Jesus must have experienced in the garden of Gethsemane,” you know? Truthfully energized enlightenment, and that makes a difference because often, these ketogenic plans, we are not doing them correctly. We’re not eating enough vegetables, but it’s 25%, I will say, this is my statistic, so I haven’t verified this, but I would say our health, our optimal health is 25% diet and exercise, right? The same with keto-alkaline. If we’re not walking in nature, if we’re not reducing the EMFs, if we’re not sleeping well, we’re not going to be able to maintain a healthy keto-alkaline status. Yes, again, there are limitations to urinary testing for ketones, but let me tell you all, when we get these women, like I’ve run now over 300 women through my Magic Menopause program, when we get them persistently alkaline, their life shifts.
Not only that, their relationships shift. Their weight shifts, their quality of life shifts and they get a twinkle in their eye again. That’s huge.
Dr. Fitzgerald:
That’s amazing. What vaginal pH are you going for? What’s your optimal range?
Dr. Cabeca:
This was urinary pH.
Dr. Fitzgerald:
I’m sorry, yeah, urinary pH
Dr. Cabeca:
Urinary pH testing for alkalinity and ketones. For urine pH, I want to see a pH of 7. I just want to see a pH of 7, and that’s it. On my strips, it’s just show me some green, and that makes it really easy for women that can’t afford … My women are doing a virtual programs. Many of your providers may have virtual programs, so I’m not testing them or ordering specific labs for them, so they are able to kind of shift their body themselves by just checking to get alkaline, and then bump their body, periodically, into a ketogenic state. Then, we can reliably look at urine ketones. Once we’re in a ketogenic state for a long time, we’re not going to see it in our urine. Hello, in America, show me a woman that’s persistently ketogenic. I mean, that might be a 0.0001% of us. Let’s use something cheap and effective and also allows women to do kind of what I call their Nancy Drew detective work. I want to see their vaginal pH of 7 and I just want to see some ketones at least three days a week.
Dr. Fitzgerald:
Okay.
Dr. Cabeca:
That makes a big difference.
Dr. Fitzgerald:
That’s fabulous. This is such a great pearl. The alkalinity is just keeping you accountable for veggie intake for probably loads of fabulous leafy greens and so forth, just making sure they’re there, and then transitioning into periodic ketosis is terrific. What do you look for on your urine strips with ketosis? Trace, small, moderate?
Dr. Cabeca:
Yeah, just show me some.
Dr. Fitzgerald:
Show you some, any change?
Dr. Cabeca:
Show me some, any. Yeah, But then I would say what we want to see is it’s going to be great when you get the green and red going, and you feel like Christmas, it feels like Christmas.
Dr. Fitzgerald:
Wow.
Dr. Cabeca:
Yeah. It feels that. I mean, you do have this amazing amount of energy and clarity. It is interesting what can interfere with that in our lives, one bad night’s sleep can bump us out of alkalinity. Medications can bump us out of alkalinity, but also ketogenic diets will make women acidic. Maybe in men, maybe men are more able to stay alkaline better, but in women it is not ideal without adding on. There’s a fine line, because to be in ketosis, to be fat burning and to have enough alkaline carbs could push us out of ketosis, so there’s a fine line that women and men will have to work on to get to that state, but I believe that will be a state of optimal health. Very inexpensive.
Dr. Fitzgerald:
Yeah, extremely inexpensive. Really, really useful. I appreciate that. We’re going to start using urine pH strips. We are definitely going to use this in my practice. There’s no doubt about it. It’s so helpful that you are leaning on the lifestyle piece, because you are absolutely right, and I do see that in my patients who are very weight loss resistant. So many of us women in our 40s and 50s, we are burning the candle at both ends. We’ve got epic responsibilities and sleep is sacrificed, self-time is sacrificed, getting outside in nature, all of these important things. I know. I struggle with balance in my life and see it in my female patients as well. That’s such a fabulous, fabulous, fabulous pearl again, we’ll have your websites on our page.
Let’s talk a little bit more, though, about what you’re thinking with regard to menopause. You had mentioned in your early evolution you are using bio-identical hormones, but I know you’re using some botanicals in there as well. Can you tell me about that and what you might be doing now?
Dr. Cabeca:
Yeah, absolutely. One of the big things that I had started using in my practice were absolutely botanicals. Specifically, Maca, right? Part of my story is that I had left my medical practice for a year in 2006 and took my kids, home-schooled them traveled around the world and I learned from healers around the world and I learned medicinal foods. Part of that was a healing journey for me and my family. I came across and learned about different botanicals. I kind of grew up in a Middle Eastern household, a philosophy of food as medicine, like my mom would always say, “Okay, if you want to get straight A’s, eat this Za’atar,” which is thyme and sesame and olive oil mix. “Eat this Za’atar with olive oil and you’ll get smart. It will help you.” Or “If you have a belly ache, do this and it will help you.” I kind of grew up with that philosophy.
Then, when I had gone through my own personal emotional and physical health crisis, I just looked for answers. I looked for spiritual answers and medical answers as well. That took me to healers of all kinds, from the leaders of universities in New Zealand, Israel and Germany to indigenous healers in Indonesia, Brazil, Native American, Peru. It was fascinating, but a few of the ingredients I learned from the foods that I believe helped me, number one, restore my fertility after a tremendous diagnosis of early menopause and permanent, irreversible infertility, I started using many of these indigenous foods, including Maca from Peru, and then Spirulina and greens and different ingredients along the way, which is part of the reason, I believe, you know, God had a strong hand in this and in my life and in the direction that I restored my fertility.
My fertility was restored, I became pregnant with a beautiful daughter, Anna Marie, at 42. That was huge. I learned and I wanted to bring that information, and I wanted to bring those ingredients in an easy way for my clients, for me, primarily, selfishly, and my family I worked to formulate my Mighty Maca Greens formula, which has Maca in it. I believe that’s a key ingredient, but also the other naturally anti-inflammatory ingredients or ingredients that support your natural anti-inflammatory pathways or natural inflammatory response to help support that, including turmeric, including green tea extract, including our greens and enzymes and Una De Gato, which is cat’s claw, which is a potent, great ingredient, herb, to use, especially if there’s a history of cancer.
42 ingredients, I couldn’t stop it. I use that, and as well, the importance of oils, Omega 3s, ELA for breast health. Now, many women suffer from vaginal health issues. From vaginal dryness and from incontinence. I mean, the rows and rows of incontinence pads that you see in the grocery store should alert us that there’s a significant problem, and women deal with this, and they often deal with it silently and shamefully. Between the lack of sexual desire, lack of bladder control, which starts to inhibit their activity, including running, jogging, yoga, different things where they could lose bladder control. It becomes significantly detrimental. If we have enough time, I’ll give you a scenario of what happens and where I developed using vaginalhormones, I really would love your prescribers to be very comfortable prescribing vaginal hormones, because it makes a difference.
I will lecture to a group of OB/GYN’s and physicians and ask how many people use vaginal hormones or will write a vaginal hormone prescription other than estrogen? A fraction, if any, will raise their hands. The important truth is, Kara, which I really want to emphasize to our listeners is that estrogen only works on the mucosa, and unfortunately it’s what we will feel comfortable prescribing, but truthfully what improves vaginal muscle and the connective tissue is androgens. Testosterone, DHEA, I mean, you can use these hormone prescriptions vaginally and that totally regenerates and rejuvenates the vaginal tissue, sexual health, incontinent symptoms. Similarly, with my surgical practice of working on incontinent procedures, I went to, I mean, I used it to operate doing bladder procedures, that was a key thing, treating incontinence, and then I started thinking, “Oh my gosh, well, there’s all this, we hear about the mesh erosions.” Thankfully, I’ve never had any. I would always use vaginal estrogen preoperatively, so then I started using vaginal DHEA and testosterone preoperatively to improve my surgical procedure as well as the surgical outcome.
You want good tissue to suture, right? Working on bladder slings, vaginal prolapse, all those things, you want good tissue to work with, and so I would start using vaginal androgen therapy. My clients started coming back for their preoperative visit after I put them on a month of vaginal hormones, and then I would have the pre-op and they would tell me, “Well, I’m not having any more leakage.” I’m like, “What?” I’m like, “Wait, I guess I can’t operate.” They’re like, “You mean I don’t need surgery?” I’m like, “If you’re not having symptoms, I don’t need to operate,” and I would reexamine them and their symptoms would improve and the objective data with urethral mobility and stuff would improve.
I’m like, “Whoa, this is blowing my mind.” Then, I started using it on clients who did have, from other surgeries, mesh erosion or sutures penetrating through the vaginal mucosa and I started using vaginal hormones before I would repair the area, and honestly it repaired itself. I went, I remember one day I did 6 vaginal slings in one day and I haven’t had to do another one in years. Yeah. That’s huge. Vaginal hormones. It’s been powerful.
Dr. Fitzgerald:
First of all, I want to circle back. I know the Maca products, I know you have talked about them quite a bit and it sounds like you’ve really made a beautiful formulation. Is that available?
Dr. Cabeca:
Yeah, absolutely. It’s at Mightymaca.com, and we do have physician affiliate programs.
Dr. Fitzgerald:
Okay, sounds fabulous. Now, I want to talk specifically about some of these hormonal protocols. Can you give me the lowdown of what you’re doing in practice now? The vaginal hormonal protocols, because everybody is going to want to know.
Dr. Cabeca:
Yeah, absolutely. One of the big things that I do with vaginal is one of the things that I did is typically, if I have a client that has significant incontinence symptoms, I would write a testosterone vaginal suppository. Now, you’re compounding. None of this is available through a standard prescription, you have to use a compounding pharmacy. I started getting really creative. I worked with my compounding pharmacy to really create beautiful suppositories that are nourishing and small. Not these big ones that they used for rectal. They’ll often say, “Oh, well let’s use the rectal suppository size for the vaginal.” I’m like, “Ugh, gross.” Discharge, I mean, it’s just a mess. Typically, I would just start, even with a vaginal cream, you would use testosterone, 2 to 5 milligrams with 2 to 5 milligrams of DHEA, say if you’re using a cream, per ml, and begin at 1 ml daily for 30 days and then pretty much when symptoms resolve, you can go to 3 to 5 times per week for maintenance. It’s very important.
I may use weighted balls or they can do Kegel exercises also to kind of exercise the vaginal walls. We used something called Luna Beads, but I think the green egg people are … Not the green egg, what’s it called? Jade Egg, thank you. I’m thinking Thanksgiving turkey cooking in my green egg cooker. Jade Egg. You could use those, and just something to exercise the vaginal walls, or nothing, but just the hormone cream in and of itself and patients would do better. You can go up to 10 milligrams of testosterone, but only if there’s a significant issue and your patient tolerates. Now, this is a caveat that I’ve learned through my age management practices is that whenever we prescribe testosterone, male or female, that does also affect dopamine, which hence will affect novelty-seeking behaviors, which will hence not be conducive to healthy relationships.
You do need to really watch that and counsel on that because it’s a serious issue, I think, especially with these testosterone clinics and testosterone high doses that are being given to both men and women. For many of my male colleagues that have been using testosterone for a long time, the divorce rates are really high, and that’s not the goal. Not the goal. I would counsel on this, and one of my mail clients, I treated the wife and then him, and he said, “Dr., I’ve started this testosterone injection and I’m thinking thoughts about other women that I really don’t want to be thinking,” and his dose was way too high. We stopped it and restarted at half the dose, because again, it’s important to understand that physiology drives behavior and if we’re manipulating physiology, we may even be manipulating behavior to the negative and not the positive. That’s important to recognize, too.
That’s a caveat to remember, because when I’m talking about using hormones, we have to be very considerate of what we’re doing. Again, it’s backing down, start low, go slow. The same with vaginal hormones, but I like clients to see a result right away because using a vaginal suppository is not fun. That led me to create, you know, I’m always looking for solutions that are easy for women, so that led me to create my new cream called Julva, and that’s a topical cream with some plant stem cells and emu oil and coconut oil and DHEA in it to use on the vulva. That’s a beautiful cream to use that can just be restorative to the vulvar tissue, but also there’s a good improvement in vaginal dryness and vaginal health as well. The other thing to remember, when we’re using vaginal hormones, whether it’s estrogen or androgen hormones or, again, restoring hormones to the vulva as well, using hormone cream on the vulva, is that we’re going to shift the flora.
We’re going to go from Sahara to Amazon, so if there is an increase in yeast growth, or if there’s been Candida dormant or some imbalance in the bacterial flora of the vagina, maybe clients will come back with a yeast infection or discharge, and so it’s important to kind of know, “Okay, if they get a yeast infection, that’s fine, let’s just treat it. That’s been there.” It didn’t cause it, but most likely those cells have been dormant or that fungal has been there, so we’re just kind of creating a beautiful environment for it to thrive. That’s something that you may get back as a fungal overgrowth.
Dr. Fitzgerald:
Sure. Sure. Okay, so maybe initial fungal overgrowth, but I know you’re looking at diet because you’ve got this really cool keto-alkaline plan that’s going to be definitely tweaking the vaginal microbiome and the gut microbiome. You actually just sort of led us into the second, my next question, because I know you’re thinking about the global microbiome, but with an emphasis on vaginal. I would say that maybe you have this baseline yeast infection that you address, but then are you doing other things to inhibit … Diet is in there, but just the continuation of yeast infection?
Dr. Cabeca:
Oh yeah, absolutely. Plus, with my vulvar cream there’s coconut oil in there, there’s the alpine plant stem cells are anti-viral antifungal in and of itself. I think coconut oil is a great lubricant, and it has naturally anti-fungal, too, so using that for vaginal dryness or as a lubricant is a great add-on additionally. One thing, Kara, I always tell my clients is just keep your jar in the kitchen and a separate jar in the bedroom, do not cross-pollinate the two. Very important. That will wind up their attitude about it. I think that’s a really good thing to do. Probiotics, sometimes using them vaginally as well as orally, but typically oral probiotics and a healthy diet. Healthy fish oils and high DHEA content foods like we’re doing with the keto aspects of our programs, but those are tremendously beneficial for vaginal health and maintaining a healthy vaginal floor.
Dr. Fitzgerald:
That’s just wonderful. Loads of pearls, I really appreciate it. Are you thinking about, I mean, I know with vaginal hormones you’re obviously avoiding first pass, so they’re safer. Are you thinking about detox, just maintaining healthy detox in your patients as well? Is that a piece of the puzzle here ongoing?
Dr. Cabeca:
Ongoing, Kara, ongoing. I think as how do we know you’re doing a good job on it? Check your urine, make sure your pH is alkaline. At least wake up with a pH of 7. A crazy day may get you acidic, but let’s let our body restore and rejuvenate overnight, so let’s try to wake up with a pH of 7, and also the keto principle of at least keeping 13.5 hours between dinner and breakfast, aiming for 15 hours. Then, we’ve kind of got that keto alkaline protector. There’s a research paper that came out this spring looking at breast cancer and intermittent fasting, so interval between dinner and breakfast of over 12.5 hours had a significantly decreased risk of breast cancer. If we just are adhering to those principles, awesome, but when we can actually test and figure out what our body is doing and how we get there, that’s hugely beneficial.
Like I said, I’ve had 300 women in my programs from all over the world, and what I recognize is that some women do it easily and some women don’t. Some women who thought they’d been doing everything right and then finally figure out, “Okay, here were some hidden sabotages, no wonder.” It just changes the entire quality of our life.
Dr. Fitzgerald:
Give me an example, like what might a hidden sabotage look like?
Dr. Cabeca:
For example, I have this one beautiful woman who always juices, right? Here, lo and behold she’s juicing to do well but she was completely acidic. Well, heck, that shouldn’t be right. There’s a lot of alkaline fruits and alkaline vegetables, why would that be? Well, her hemoglobin A1c was up, so she was getting too much carbs, way too much sugars, and it took us four weeks to get her into fat-burning mode, to get ketones on her. That shifted things out. That’s one thing. Another thing is I had one client who was always waking up acidic and she was like, “I don’t get it,” and then her evening medication, once she stopped it, she was waking up alkaline and felt tremendously better. A medication could be a hidden sabotage. Who knew?
Dr. Fitzgerald:
Right, right. All right, I know we’re heading towards the end. I wanted to ask you, you know, memory. It does, I was just reading in, oh, by the way, actually, before I forget, ironically enough, that one site, the paper that you just mentioned regarding that fasting period between breakfast and lunch and breast cancer, if you could just send me that reference, I will post it on the site, you guys. I’ll post that citation on the site. It sounds really interesting and I know folks would want to take a look at it. I just heard a piece of research that came out recently, you know, women have better memories than men until they hit menopause and boom, then their memories are worse than men. I mean, what are you doing there? I’m sure this overall plan is helping, but just what are you thinking about with regard to just the brain fog, just the pesky memory, executive function stuff that happens during this time?
Dr. Cabeca:
Yeah, totally, send me that link for that research paper. I’m very curious about it. I will tell you, yes, brain fog is a huge issue for us in perimenopause and menopause. Often, again, when we use progesterone, especially women who have had their uterus removed and they been only on estrogen, but when we start using bio-identical progesterone, patients report back to me, “I feel like the fog has lifted,” over and over and over again. Now, again, progesterone is huge for memory. Right? We’ve got progesterone receptors within our brain, and that’s why they’ve been researching progesterone for traumatic brain injury, etc. Progesterone is huge, and my combination, my Pure Balance cream is progesterone/pregnenolone combination, so that is, again, great research for that and memory. I love the combination of the two, progesterone and pregnenolone. Now, let’s take into consideration what’s happening in the perimenopause/menopause, but also, Kara, when women have had any, like myself included, experience of a traumatic event, so PTSD, or women who have had early childhood trauma or veterans from war, female veterans from war experience a very tumultuous time in the menopause, and especially with memory loss.
What we’re seeing is that cortisol dysfunction creating memory loss. Really reestablishing the balance and reestablishment of a healthy circadian rhythm, healthy sleep cycles, getting alkaline, which will increase our ability to balance cortisol. I always say alkalinity helps with cortisol, ketosis helps with insulin sensitivity. Those are my two huge concepts. Then, oxytocin, the crowning hormone, is the hormone of life in general. Go into that. With memory loss, this is huge, and I think that it’s devastating for us when we are experiencing that. Personally, PTSD took my memory to the cleaners, basically, and that’s when I started recognizing when I had a pretty darn excellent memory, especially a visual memory and an auditory memory, PTSD took that memory away. Studying how to restore it is huge.
Until I get and stay, when I get into this keto-alkaline state that I’m talking about, there’s so much clarity. Yes, I’m using progesterone cream and yes I’m using DHEA, my vulvar cream, and yes I am a proponent for bio-identical hormones and nutrients and supplements, but now that I can really check and see that I’m getting into this keto-alkaline state regularly, the fog clears. For women in the menopause, for whatever evolutionary reasons, that design of being carb-restricted, but yet with beneficial, alkalizing ingredients, it makes a difference on our memory. That’s huge, but the studies aren’t there yet.
Dr. Fitzgerald:
Well, it sounds like you’re pulling together a good database. You’ll need a post-doc in there to write up all this stuff.
Dr. Cabeca:
Yeah, send me one.
Dr. Fitzgerald:
I know, I know. Oh, Anna, it was just so great to talk to you today. You’ve just given us epic pearls. I’m sure that any clinician, any regular person listening to this podcast is going to be so inspired by your message, you know, your own journey, your journey as a healer, just all of it is wonderful. The work that you’re doing and the inspiration around creating these products and these programs. They make so much sense and they’re so grounded and effective. It just sounds like you’re doing fabulous work for women’s health, men’s health and the functional medicine community and again, thank you so much for joining me today.
Dr. Cabeca:
Oh, thank you. It’s been a pleasure to be here, and I love learning and conversing with you. You definitely have a way of digging information out. We covered a huge amount of topics.
Dr. Fitzgerald:
We covered a lot, we did. Everybody, I will be sure to put lots of links on the site. You’ll be able to access Anna and her work and then you can certainly reach out to me if you have any questions, but I think you’ll be able to find what you’re looking for with her and her programs. All right, again, Anna, thank you.
Dr. Cabeca:
Thank you.
Links: