In today’s podcast, I’m talking with long time integrative medical clinician and anti-aging expert Lynne Mielke, MD about her approach to bioidentical hormones and why the Precision Analytical DUTCH is her go-to test for assessing biHRT response. It’s her experience that the “gold standard” blood tests often lead to over-prescribing, and she commonly finds herself initiating tapers for those patients who come to her already on biHRT. Learn how she uses the test and prescribes biHRT (she’s started her own in-office compounding pharmacy!). And we spend some time on the topic of libido – Dr. Mielke is committed to helping women in her practice-particularly post-menopausal women- restore and maintain a healthy sex drive. Lynne also shares with us her journey to integrative medicine – as a psychiatrist, she faced the limitations of her training when her son was diagnosed with autism. As she puts it, she entered another world as she dove into integrative, biomedical treatments for autism decades ago: “Given the complexity of spectrum disorders, if you know how to treat them, you know integrative medicine.” From there, she leaped into anti-aging medicine, as parents of autistic children sought her care. Dr. Mielke shares her transition into practicing integrative medicine, and what her clinic looks like today.
In this episode you will hear:
- How Dr. Mielke uses the DUTCH test in her clinical practice
- Balancing estrogen with progesterone
- Go-to supplements for hormone metabolite patterns
- Methylation imbalance in estrogen detox: a sign of heavy metal toxicity?
- Topical hormone protocols- tissue, location matters
- Orgasms are essential: Using biHRT and lifestyle medicine to ensure they continue into menopause
- Dr. Mielke’s journey into integrative medicine, her personal story
- Advice for practitioners transitioning into integrative medicine
VISIT Dr. Lynne Mielke, Optimal Health Spectrums
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Dr. Kara Fitzgerald: Hi everybody. Welcome to New Frontiers In Functional Medicine where we are interviewing the best minds in Functional Medicine. And today is no exception. Before I jump into our amazing conversation, I just want to remind you if you’re enjoying what you’re hearing, please, please, please, consider circling over to iTunes and leaving a review.
Okay. Today we’re talking about bioidentical hormones, evaluating for them, the appropriate labs. We’re going to be talking about protocols. We’re just going to dive in deeply. I’m speaking with expert Dr. Lynne Mielke. She is an in-the-trenches clinician. She’s been doing this for years. She’s the founder of Optimal Health Spectrums, a large integrative clinic in Pleasanton, California. She graduated from Indiana University School of Medicine and then completed her psychiatry residency at UCLA’s Neuropsychiatric Institute where she became board certified by the American Board of Psychiatry and Neurology. She has received extensive training in all things anti-aging through A4M and she’s also a Fellow of the American Academy of Ozone Therapy.
Her interest and transition into integrative medicine actually started when her youngest son was diagnosed with autism and she realized that the standard medical approach wasn’t useful. Additionally, when she experienced her own age related hormone decline, she realized her concerns weren’t being met, either. So she’s gone headlong into integrative medicine and has been in this space for years, now. She lectures and trains clinicians, attends many conferences annually. She’s researching new treatments. She is considered an expert in the field.
Welcome, Dr. Mielke, to New Frontiers in Functional Medicine.
Dr. Lynne Mielke: Thank you.
Dr. Kara Fitzgerald: I want to hear about your journey into integrative medicine. You just mentioned in your bio, here, that your son was diagnosed with autism and that prompted you to expand your options.
Dr. Lynne Mielke: Yeah. I actually think a lot of physicians, nowadays, get into integrative medicine because of a personal connection, somehow, when they realize that the traditional western medicine approach is just failing in many areas of healthcare. So, in the case of autism, here I was, a board certified psychiatrist and the only thing that doctors wanted to do to my three year old son at that time was put him on Risperdal. And I was like, I am not putting my three year old on an anti-psychotic drug. And I was like, there has to be something else out there, something better.
So I started attending … at that time, it was Defeat Autism Now conferences. And I remember, this was like a religious conversion or something, when I realized there was this entire other world out there of integrative medicine. And I had been denied that training in medical school. No exposure to that whatsoever. It made obvious sense to me that this was the right approach for many health issues.
So, I started attending all these conferences and gradually shifted out of psychiatry and into integrative medicine.
Dr. Kara Fitzgerald: Yes, right. I used to go to the DAN Conferences also, and they were just really, really great resources. I’m just curious, did you … just briefly, because we need to move on the topic at hand. But I’m just curious what you ended up doing with your son. You obviously found some good outcome or you wouldn’t have continued on this path with such a robust commitment.
Dr. Lynne Mielke: Well, we’ve done everything with him from chelation to special nutrient therapies. Lots of gut issues, of course, healing that. Working on … I mean, autism is such a comprehensive, multi-system health problem that I have said, and anyone who understands how to treat autism understands integrative medicine, basically. It’s an amazing treatment, if you will, how comprehensive the treatment protocols have to be when you’re dealing with an autistic child. Autoimmune issues, brain autoimmunity. I mean, so much going on. So they’re very complex patients but very rewarding when you can help them.
Dr. Kara Fitzgerald: Yeah. Absolutely. So, then, again, necessity is the mother of invention. You started to have some hormone fall outs yourself.
Dr. Lynne Mielke: And a lot of the parents…. A lot of the parents of the autistic kids were like, can you treat us? And at that point, I was only treating autistic children. And I was like, well, yeah, I guess I could expand my practice into adults. And then, realizing that adults need that hormone piece in addition to the regular integrative medicine and everything else that we do.
Dr. Kara Fitzgerald: Yes.
Dr. Lynne Mielke: So, attended a bunch of hormone conferences, mainly through A4M. They have a lot of good training courses on that. And, that’s when I started doing it. In the beginning … I always say when I went to those initial lectures, I was hearing experts in the field saying the right way to monitor hormone therapy is through blood testing. And then the next speaker would say, no, saliva testing. And then the next speaker would say urine testing.
So, I, being a new practitioner at the time, was like, well, which one is it? Because these true experts are all saying different things. So, what I ended up doing, in the beginning, was testing several patients all three ways. And it became very clear pretty quickly that the urine testing, the 24 hour urine, or its equivalent through the Dutch test, was the only method that essentially gave me the results that were correlating perfectly with the patients’ symptoms. I found with saliva and blood, that the result could be high or low, and that would not necessarily be corresponding to what the clinical picture was, the patient was showing me.
And, what I really like about the 24 hour urine test is that when a patient has symptoms of low estrogen, I can guarantee that test is going to show low estrogen. And, it just always is this nice correlation with the clinical picture.
Dr. Kara Fitzgerald: And so, you’ve moved over to using urine exclusively?
Dr. Lynne Mielke: Yes. A lot of patients do ask me, can you please check me with blood? Because the advantage of that is it’s simpler. It’s one quick blood draw, covered by insurance, often. But I just find it so incredibly unhelpful that I basically don’t do it.
Dr. Kara Fitzgerald: Wow. So even though it’s standard of care. I mean, we still, I have to be honest, and say we do both in my practice routinely. But, like yourself, I’ve found urine to be very useful. And yes, I agree that it does correlate.
Talk to me about, you’re using Dutch, and how you found and landed on them. I mean, there’s other urine options out there.
Dr. Lynne Mielke: Yeah. I started out with multiple other companies. One of the big advantages of the Dutch is for … my nickname for it is the four spot. I call it the four spot. Because it’s like four spot urine collections, and maybe five, if they do the overnight urine. But anyway, it’s just so much more convenient to be able to not have to carry a jug around for 24 hours. So that’s a huge advantage for a lot of people. I have found some people get confused by the instructions on this test. So I actually have made my own simplified instructions. We even have a time line printed out. Like, put the hormones on here, collect the urine here. And so, it really helps our patients with how to do the test correctly.
Dr. Kara Fitzgerald: Wow, that’s interesting. Listen, if you’re open to sharing that with my listeners, we can put it on your show notes page. That sounds like it would be really handy. That would be great.
Dr. Lynne Mielke: Yeah.
Dr. Kara Fitzgerald: And then, and you’re finding after you initiate treatment that using Dutch for follow up is also useful?
Dr. Lynne Mielke: Oh, yeah. I mean, that is what I use along with, obviously, their clinical symptoms to decide how to adjust hormone dosing.
Dr. Kara Fitzgerald: Okay. And what are you looking at, specifically, on the Dutch test?
Dr. Lynne Mielke: Well, I’m looking at every single piece of information on there. But, again, I do want to see a good balance between the progesterone levels and the estrogen levels. I want to see a nice balance between all of the hormones. Because it’s that concept of the symphony, you want all the hormones at a good level. And if the progesterone is at the low end of range and the estrogen’s, for instance, at the high end of range, I’m going to definitely want to increase that progesterone to bring it up so that there’s a good balance. We always use the analogy with the patients of the gas pedal and the brake. So the estrogen is like your gas pedal. It’s a growth signal. It makes tissues grow and divide. And so, the progesterone is the brake. It is the anti-growth signal. So we need to have those things balanced.
And I do see a number of patients who tell me, well, my gynecologist said I don’t need progesterone because I had a hysterectomy. And I say, you still need progesterone because progesterone has all kinds of benefits for the entire body, including the brain, it helps prevent breast cancer. So, I say, you may not have a uterus, but you probably still have breasts. So, you do need progesterone.
Dr. Kara Fitzgerald: Yes. Absolutely. And you’re comfortable with the fact that using urine as a specimen means you’re not directly looking at progesterone, but you’re looking at metabolites?
Dr. Lynne Mielke: Yeah, indirect. But, yeah. Absolutely. It’s a very … again, I find that it correlates very well. If someone is low in progesterone, they may be having symptoms of heavy bleeding or cramping or insomnia or symptoms of low progesterone. So, I basically find, again, that even though it isn’t a direct measure, it correlates very well with the patient’s clinical picture.
Dr. Kara Fitzgerald: Good. Good. And what about the metabolites? You obviously must be looking at those. What are you thinking about with regard to the 16 hydroxyestrone and the 4 and the 2 hydroxyestrones?
Dr. Lynne Mielke: Yeah. I mean, we definitely look at that. And if the 4 or the 16 is high, I will put them on the DIM or something called Indolplex IC3. So we … I use those supplements all the time. I find most women have pretty good metabolites on their own. But there’s a small percentage where you have to put them on one of two of those kind of supplements. But, I have a few patients in the practice where we’ve had to go up to four to six of those supplements in order to shift them over into the two hydroxy metabolites.
Dr. Kara Fitzgerald: Okay. Got it. Now, what about … so 16 hydroxyestrones, sometimes we think in post menopausal women, that some background of 16 actually is beneficial because it’s pretty potently estrogenic. What are your thoughts on that?
Dr. Lynne Mielke: Well, I mean I feel like if you’re giving estrogen and you’re bringing their estradiol levels up, that’s what is the most important thing.
Dr. Kara Fitzgerald: Right. So you want to see a clean balance of the metabolites and probably …
Dr. Lynne Mielke: I want all three estrogens in good ranges.
Dr. Kara Fitzgerald: Now, what about the 2-methoxy and looking at methylation activity? What are you thinking about there?
Dr. Lynne Mielke: Well, I always look for that. That’s one of the things I really love about the Dutch test, is that it gives us that methylation marker. So, I always do, as part of my initial work up, the MTHFR gene and we look at what that is. And if we’re having trouble after giving methyl B12 and the methylfolate and other kinds of methylation support, if they’re still not methylating, I might even do a 23 and Me, get their entire methylation panel and look at other, COMT and other genes. But, the test gives us this beautiful dashboard indicator of methylation status. And I find that sometimes someone’s methylating and then the next time I do the test, because I do it twice a year, I find that, oops, their methylation dropped. And they go, oh yeah, I ran out of that methylfolate and didn’t refill it or something. You an always see that. It’s very helpful.
I say, if you’re not methylating your hormones … and again, this has cancer protective effects, then you’re not methylating your neurotransmitters. You’re not methylating anything properly in your body. So it’s very important to understand it’s not just the hormones. But this is a systemic methylation thing that we’re looking at.
Dr. Kara Fitzgerald: Right. Right. What about … so 4-hydroxyestrone, sometimes we see that really high. We can do some … use interventions for slowing down production. But what about the possibility of the damaging DNA, some of those quinone adduct potential? Are you doing interventions on that side attempting to inhibit the formation of quinone adducts?
Dr. Lynne Mielke: Well, I have found that usually just giving the DIM or the IndoPlex kind of thing helps lower that as well. It pretty much takes care of both, in my experience on the test.
I did want to mention one other thing about the methylation thing, though. I have found that if someone is taking all their methylation support and this test still shows that they’re not methylating, one thing that I have really noticed is that frequently that’s because they have a heavy metal problem. And I start doing like an IV chelation challenge test on them and then find out that yes, in fact, they do have metals. We chelate for a while. Then we go back and redo their urine test, and low and behold, all of a sudden, they’re methylating now.
Dr. Kara Fitzgerald: Methylation is opening up. Okay good. That’s a nice pearl. How are you collecting your … how are you evaluating your metals, out of curiosity?
Dr. Lynne Mielke: Well, I prefer to do an IV test. So I start everyone at 2 mg per kilogram of DMPS and 20 mg per kilogram of calcium EDPA in the same IV. And then we collect a six-hour urine after that. So they start with an empty bladder and get that IV, collect six hours of urine after they go home. And we give them careful instructions how to do that. And then we know what it’s supposed to look like, basically, after having done thousands of these. I always tell people, everyone on earth has some metal. We’re not expecting it to show up as zero. But, if lead or mercury’s across the page, or we see a ton of cadmium and arsenic and so many metals …
Dr. Kara Fitzgerald: Yes.
Dr. Lynne Mielke: We find that people often have no idea where they were exposed to these things. And then, we will design a chelation protocol for them. Some people want to do it orally. But I do find that oral is more likely to cause stomach upset and yeast overgrowth and this and that. So I tend to not use a lot of oral chelation. But, the IV is very well tolerated. Very few side effects, and gets really good results. It’s one of the best ways … the calcium EDPA IV is the best way to pull lead from the bone, for example.
Dr. Kara Fitzgerald: Thank you for that. Now, what about … what kind of levels are you looking at? Let’s say you’re treating kind of a perimenopausal symptomatic woman. What do you want to see after HRT? And we’ll talk about your HRT protocols in just a second. But, what are you looking for on the labs?
Dr. Lynne Mielke: Well, I’m looking for mid-to-lower-mid premenopausal levels.
Dr. Kara Fitzgerald: Okay. And what about testosterone and testosterone metabolites and DHEA? What do you think about …
Dr. Lynne Mielke: I put a lot of … I put pretty much, almost every women on testosterone and/or DHEA. Again, I tell people, DHEA, I like to see on this urine test levels of two to three hundred. The reference range is very broad, as in the urine, for that metabolite. But I want to see a level of at least a hundred to three hundred. And women tend to, and men, but in this case, women, feel better on DHEA. And if their testosterone is low, I also prescribe that.
Dr. Kara Fitzgerald: So you’ll do both concurrently?
Dr. Lynne Mielke: Yeah. Absolutely.
Dr. Kara Fitzgerald: Okay. And, are you paying attention to the metabolites?
Dr. Lynne Mielke: Oh, yeah. I do find that if they do have high … the 5-alpha reductase, then basically they get … those are the women that are more prone to get acne and hair loss problems.
Dr. Kara Fitzgerald: Okay. Yeah, go ahead.
Dr. Lynne Mielke: So, if they have a high level of that enzyme, I will put them on a saw palmetto product, bring that down, and then that helps them with their acne or their hair loss issue.
Dr. Kara Fitzgerald: Now, just before we jump over into protocol, I’m sure you’re obviously thinking about the whole HPA axis and you’re looking at cortisol and you’re looking at thyroid. I love the cortisol awakening response on this test. And then, in the context of an overall protocol, what are you looking for here?
Dr. Lynne Mielke: Well, I mean, obviously adrenal fatigue is huge problem. So I definitely look at their cortisol curve and that is one of the nice things about the four spot urines is that … I used to do saliva cortisol, that was the one hormone I tested in saliva. But now its nice because they can get that all together if you need it. So I just basically look, and if the cortisol is low and if their metabolites are off, you know, the cortisol, cortisone kind of thing, I give them some adrenal herbs and that just helps balance that out and helps them. If they’re super flat-lined, I might consider a low dose of hydrocortisone for a short time.
Dr. Kara Fitzgerald: Mm-hmm (affirmative) yep. And how are you dosing that, out of curiosity?
Dr. Lynne Mielke: Well, we have the five milligram tablet and I, you know, depending how low they are I would start them on a full tablet in the morning and a half a tablet in the afternoon, early afternoon. That dose seems to work for most people. There’s a small percentage of patients that are super sensitive and we have to sometimes compound it down to one milligram. But most people tolerate a half to a full tablet. I find that just in the morning is the most important dose but some people need that booster dose in the afternoon because it only lasts about four to six hours in the system is what I usually tell people.
Dr. Kara Fitzgerald: Alright, yes. Yeah. In my experience also, it seems like an afternoon dose is in order for a good number of our patients. Well, so you talk about compounding, one of our neat off-air conversations, was that you actually are doing in office compounding and I know we won’t walk through the whole details of how you set that up. You can maybe give me a high-level idea but I want to talk about how you’re putting together your bioidenticals, you know, how you’re prescribing them, the dose, the root, the carrier oils, et cetera.
Dr. Lynne Mielke: Yeah, well, I find that for the vast majority of women, a Bi-est 50/50, 50% estradiol, 50% estriol product at … and we have a two milligram per gram and four milligram per gram Bi-est, and I also have a straight estradiol only, at one milligram per gram and two milligram per gram. And as far as estrogens, I find that those four formulations cover the vast majority of my patients needs. For progesterone, I have 100 milligram per gram and 200 milligram per gram cream, and we also compound a five milligram oral capsule. That is more for men actually. And we also have then a 50 milligram and 100 milligram capsule, again finding that for most people those are the doses that will cover them. And testosterone, I have a four milligram and an eight milligram per gram, and DHEA, 40 milligram per gram, 100 milligram per gram.
So again I find, and I always tell my patients this, that there are three main ways we can adjust the amount of hormone that is getting absorbed into your body. And that is, of course, what matters. It doesn’t matter so much what you’re putting on them, what matter is what gets into their blood stream and then shows up in their urine. So the three ways, I always say, is the concentration of the cream itself.
Dr. Kara Fitzgerald: Mm-hmm (affirmative)-
Dr. Lynne Mielke: How much cream you put on and the other big variable, and this is something that I think a lot of practitioners overlook, and that is where you rub it.
Dr. Kara Fitzgerald: Yeah.
Dr. Lynne Mielke: So I always tell people the two main surfaces on our body, skin and mucosa, skin is dry, mucosa is wet, and I always say for women, you’ve got your inner labia, internal vaginal and anal opening. Those are the big mucosal surfaces. I find that for most hormones, the mucosa absorbs approximately twice as much as skin.
Dr. Kara Fitzgerald: Mm.
Dr. Lynne Mielke: So you can essentially get double the effect by putting the same cream on mucosa versus skin. And, another little thing that I have found, I don’t know if you’ve seen this in your practice, but it appears to me that progesterone in particular, in the cream form, does not absorb that well through skin. I have found that other hormones, essentially every other hormone, absorbs pretty well through skin, but progesterone in particular I pretty much always recommend put that on mucosa because you’re going to have a lot better absorption if you put it there.
Dr. Kara Fitzgerald: Isn’t that interesting.
Dr. Lynne Mielke: Yeah I don’t know why, and I actually have, but I’ve just seen that over and over, that the other hormones are absorbing through their skin, progesterone levels come out low on the test and we put it on mucosa and now we’re fine.
Dr. Kara Fitzgerald: Wow, isn’t that
Dr. Lynne Mielke: So
Dr. Kara Fitzgerald: That’s a good pearl
Dr. Lynne Mielke: I don’t know why.
Dr. Kara Fitzgerald: You know I actually, so probably similar to you, I was taught to rotate skin sites, that was the original and then we sort of made this wholesale shift towards just inner thighs, where there’d be a, almost like a sustained release, because it would be accumulated in that local adipose tissue.
Dr. Lynne Mielke: Right.
Dr. Kara Fitzgerald: I continued to do it that way for that reason
Dr. Lynne Mielke: Mm-hmm (affirmative)-
Dr. Kara Fitzgerald: And I do see…
Dr. Lynne Mielke: Right.
Dr. Kara Fitzgerald: absorption, but I think time to benefit is longer and obviously I could bypass that if I started somebody on applying it, you know, vaginally to the vaginal mucosa
Dr. Lynne Mielke: Yeah
Dr. Kara Fitzgerald: So that’s a
Dr. Lynne Mielke: Well actually it’s
Dr. Kara Fitzgerald: good pearl
Dr. Lynne Mielke: Especially if it’s a woman who’s a little older and has serious vaginal dryness I
Dr. Kara Fitzgerald: Yes
Dr. Lynne Mielke: Always tell them immediately put that estrogen cream internal
Dr. Kara Fitzgerald: Yes.
Dr. Lynne Mielke: Vaginal, and you know then they say how long is it going to take, and I usually say two to four weeks for that vaginal tissue to kind of you know plump up, but they don’t need any other product other than that. The vaginal estrogen just takes care of it really well.
Dr. Kara Fitzgerald: Yes, yes. Well Anna Cabeca just came out with a topical DHEA, are you using that?
Dr. Lynne Mielke: Yeah
Dr. Kara Fitzgerald: In the vaginal
Dr. Lynne Mielke: I use DHEA cream all the time, yeah.
Dr. Kara Fitzgerald: Okay. Alright, and how are you prescribing that?
Dr. Lynne Mielke: In my office I use color-coded topi-clicks, because I just find that it’s a very simple device to use. So, our estrogen products are all in a pink topi-click, the testosterone is all in a blue topi-click, and I put DHEA red. Red and blue are considered more masculine colors, those are androgens. Of course the estrogen is pink and the progesterone cream is purple. The colors make sense to people, it’s easy for them to remember.
Dr. Kara Fitzgerald: Mm-hmm (affirmative)-
Dr. Lynne Mielke: And so they can tell me, well I’m on the purple cream or whatever and I know exactly what they’re getting, obviously there’s different strengths, but I know, obviously from my records, what they’re getting. It’s a very easy way to dispense the cream and again skin, I use a lot of the upper inner thigh as well, but if they’re not absorbing, we move it to mucosa.
Dr. Kara Fitzgerald: Mm-hmm (affirmative)-That’s really, that’s good I’m actually going to employ that in my practice and pay attention.
Dr. Lynne Mielke: Mm-hmm (affirmative)-
Dr. Kara Fitzgerald: Talk about, well specifically offline, we were discussing the whole stress phenomena on progesterone. Oh and the other piece I wanted to ask you about progesterone, is are you ever going orally for women when you want to
Dr. Lynne Mielke: Oh yeah.
Dr. Kara Fitzgerald: Increase
Dr. Lynne Mielke: Definitely
Dr. Kara Fitzgerald: CNS some of the metabolites, yeah, okay.
Dr. Lynne Mielke: Absolutely, I have a lot of my women patients taking it orally and for one reason is, if they’re on testo DHEA and estrogen cream already, and remember progesterone needs to be mucosal, there are some women that don’t like putting cream down there, it’s like it can be kind of goopy, you know?
Dr. Kara Fitzgerald: Yes.
Dr. Lynne Mielke: And, if they are having any trouble sleeping, I frequently do just prescribe it as the capsules, because it’s easier to take and it does help them with sleep, and it’s one less cream they have to deal with.
Dr. Kara Fitzgerald: Right.
Dr. Lynne Mielke: It’s a great option.
Dr. Kara Fitzgerald: They they’ll accumulate some of those really wonderful progesterone metabolites, like the alpha pregnanediol.
Dr. Lynne Mielke: Yeah, yeah.
Dr. Kara Fitzgerald: What cream, what is the base that you’re putting.
Dr. Lynne Mielke: Oh, the base, the base cream?
Dr. Kara Fitzgerald: Mm-hmm (affirmative)-
Dr. Lynne Mielke: It’s just a HRT cream, there are you know I can’t remember the exact name of it right now, but there are some that are good for skin and mucosa and there are some that are mainly just for skin. You don’t want anything with alcohol in it, obviously if you’re going to be potentially putting it on mucosa. There are standard compounding base creams. I use to actually use this super organic olive oil base cream. The problem is, with no preservatives and all that, and the problem is that stuff would get moldy sometimes.
Dr. Kara Fitzgerald: Right.
Dr. Lynne Mielke: So, if it sat around for very long. I ended up just switching over to the standard compounding hormone cream and there are several standard formulations of base cream that can be compounded with these different formulas.
Dr. Kara Fitzgerald: And pregnenolone are you using that
Dr. Lynne Mielke: Mm-hmm (affirmative)-
Dr. Kara Fitzgerald: With your patients much?
Dr. Lynne Mielke: Yeah I do. I actually do recommend sometimes again pregnenolone cream for some, but I also use pregnenolone capsules, ten and thirty milligrams and I usually do that at night. If it’s someone who’s got serious memory or Alzheimer’s problems, I may go ten milligrams twice a day, or something like that, to help with their brain function, but yeah we’ve ..
Dr. Kara Fitzgerald: And you’ll –
Dr. Lynne Mielke: I use pregnenolone.
Dr. Kara Fitzgerald: And will you measure that in blood?
Dr. Lynne Mielke: Yes.
Dr. Kara Fitzgerald: Will you track it?
Dr. Lynne Mielke: I should have said, yes there are certain hormones, obviously thyroid is in blood
Dr. Kara Fitzgerald: Yes
Dr. Lynne Mielke: Pregnenolone is in blood. I sometimes will do DHEA in testo, DHEA-F in testo, in men especially with blood. And I do baseline testing, when a patient first comes in and they’re not on hormones, I will do a baseline blood test.
Dr. Kara Fitzgerald: You will.
Dr. Lynne Mielke: And I find, yeah, just as a baseline, I tell people this is like a ball park. It gives me a basic ball park of where you are, but it doesn’t tell me how your hormones are fluctuating day to day, or over the course of the day.
Dr. Kara Fitzgerald: Mm-hmm (affirmative)-
Dr. Lynne Mielke: I do do some blood testing, it’s just that when someone is taking hormone cream, or progesterone capsules, I find the urine test is much better for monitoring.
Dr. Kara Fitzgerald: Okay.
Dr. Lynne Mielke: I have found this, I’ve had patients come to my practice from other doctors who are prescribing them hormones and one in particular, comes to mind. This woman was seeing one of these fancy doctors in LA, who was like the doctor to the stars kind of thing and she had been taking this whole hormone regimen from this doctor down in LA. And, she came to my office and told me what she was taking and I was shocked, I was absolutely shocked and appalled. The woman was on thirty times more estrogen, then what I prescribe.
Dr. Kara Fitzgerald: Wow.
Dr. Lynne Mielke: It wasn’t just a little bit, it was this massive amount of estrogen and I was like, I knew immediately, I said how did your doctor test your hormone? She said blood and I said yeah. It’s to the point where I already know, if a patient comes in on a high level of hormones, I know that it’s because their doctor was blood testing them.
Dr. Kara Fitzgerald: Wow, and she obviously came to you because she felt horrible.
Dr. Lynne Mielke: Well she moved actually.
Dr. Kara Fitzgerald: Oh, oh.
Dr. Lynne Mielke: Here’s the amazing thing, she had moved from southern California to northern California. Now she said I feel fine.
Dr. Kara Fitzgerald: Huh.
Dr. Lynne Mielke: And so, I said look I need to do this urine test, because I understand that you may feel fine. This is another interesting thing, I have found that there are some patients who are very sensitive to subtle changes in their hormone levels, like tiny adjustments and they really feel it.
Dr. Kara Fitzgerald: Mm-hmm (affirmative)-
Dr. Lynne Mielke: And, there are other patients, that seem to be completely immune to hormone side effects. That is why you can’t a hundred percent go by symptoms, you have to have this urine test to help guide your decision making.
Dr. Kara Fitzgerald: Yes.
Dr. Lynne Mielke: This woman, when she did the urine test, I said you’re going to come out high.
Dr. Kara Fitzgerald: Yeah.
Dr. Lynne Mielke: She said my blood tests were fine, and I knew it, her urine test was super high. So, basically, I had to slowly and gradually decrease her dose, and what was interesting, she felt fine the entire time I did that.
Dr. Kara Fitzgerald: Mm-hmm (affirmative)-
Dr. Lynne Mielke: And, we got her down to these much lower levels and she’s doing well and her tests are coming out normal through the urine and everything’s good, but I mean it concerns me that there are some doctors out there that are prescribing these high levels of hormones, because they’re testing through blood.
Dr. Kara Fitzgerald: Right, right, I’m sure her metabolites must have been off the chart.
Dr. Lynne Mielke: Yeah, yeah.
Dr. Kara Fitzgerald: Well, just thinking about that, and you know hormone related toxicity, what are you doing in your broader functional approach with these women and men? What, so if you’ve got somebody on bioidentical hormones, what else, and you actually already did talk about using dim or i3c to manage metabolites, but what are you, are you talk
Dr. Lynne Mielke: Methylation supplements yeah.
Dr. Kara Fitzgerald: And methylation yeah, are you talking to them about other pieces of the puzzle, like dietary changes, other nutrients
Dr. Lynne Mielke: Oh absolutely.
Dr. Kara Fitzgerald: I was thinking about detox, I mean the full
Dr. Lynne Mielke: Yeah.
Dr. Kara Fitzgerald: Okay.
Dr. Lynne Mielke: Oh, everything. I mean when I see a new patient, I tell them that my clinic is not just hormones, we’re not just one thing, it’s the whole system approach, so I do a very comprehensive initial workup. Lots of blood tests, you know looking for tons of markers. I use True Health Diagnostics lab, they have just a huge number of health markers and you can make custom panels, and it’s very reasonably priced. So, I set up a custom panel through True Health. I do that for blood. I do a spectra cell micronutrient panel on every new patient. Very interesting to see what their nutritional status is. I do food intolerance testing. I do stool testing if that’s indicated, if they have any kind of GI symptoms. The whole gamut, I do urine porphyrins as an interesting first morning urine screen for heavy metals.
Dr. Kara Fitzgerald: Mm-hmm (affirmative)-interesting.
Dr. Lynne Mielke: Then of course, if that is suggestive, or if they’re not methylating, despite methylation support, then we do that IV challenge test for their heavy metals, which is much more comprehensive and much more accurate, but more invasive and more expensive, so that’s why the porphyrin is a good screen, but then there’s also other tests that you can look at on their blood, that are markers for potential metal toxicity like oxidative stress markers like F2-isoprostane in urine.
Dr. Kara Fitzgerald: Mm-hmm (affirmative)-mm-hmm (affirmative)-
Dr. Lynne Mielke: If that’s elevated frequently, they have a heavy metal problem.
Dr. Kara Fitzgerald: And are you getting that through True Health as well? Do they offer that?
Dr. Lynne Mielke: Yes. Yes, they do. Then things like myeloperoxidase, that’s another marker I always say, if that’s high they’re probably losing brain cells because of their oxidative stress.
Dr. Kara Fitzgerald: Mm-hmm (affirmative)-
Dr. Lynne Mielke: Anyway, there’s a lot of good markers that we look at through them.
Dr. Kara Fitzgerald: Now, what about, the DUTCH recently added organic acids to their tests
Dr. Lynne Mielke: Yup.
Dr. Kara Fitzgerald: I was dialoguing with Mark because I did training at a clinical laboratory, when I was post-doc, so some years ago and we measured organic acids, so he and I were just dialoguing about those and he added a whole handful of them and are you finding those useful as well?
Dr. Lynne Mielke: Yeah, I mean it’s good to get a few additional markers for their glutathione status and some ..
Dr. Kara Fitzgerald: Right.
Dr. Lynne Mielke: Vitamin status and again, in the autistic kids we would frequently do a full organic acid profile.
Dr. Kara Fitzgerald: Yes.
Dr. Lynne Mielke: And so, that’s a very common thing to do in autism, so having some of those markers in the adults is helpful.
Dr. Kara Fitzgerald: Just talk to me a little bit about libido. Again, we were … chatting about this off-air, and it can be really challenging in our peri-menopausal and menopausal women. What are you thinking about looking for in labs and how are you turning that around?
Dr. Lynne Mielke: I ask every single patient, male or female, about libido. It is a topic that a lot of men and women are reluctant to talk about. I also don’t just use the word libido or drive. I also say are you able to orgasm, because some people can have drive, but can’t take that final step.
Dr. Kara Fitzgerald: So, anyway I actually really question about this and I tell people that having the right levels of hormones is what I say necessary, but not sufficient. You have to have hormones in order to be able to have sexual function, but that all by itself isn’t always enough, so that you have to, but that is like the foundational step that has to be there. So, the main libido hormones in women, once estrogen and progesterone levels are normalized, are DHEA and testosterone, those androgens.
Dr. Lynne Mielke: Mm-hmm (affirmative)-
Dr. Kara Fitzgerald: A lot of doctors are only using estrogen/ progesterone in women and of course they feel better, but it does not give them the drive, the libido, the sense of well-being, the motivation, everything that helped, but those androgens help. I always say for women, we don’t need very much, essentially one to two milligrams in cream, is all I use basically.
Dr. Lynne Mielke: Mm-hmm (affirmative)-
Dr. Kara Fitzgerald: Again, there’s a few patients that have to go three to five milligrams, but I have maybe a handful of those patients in my entire practice. Every other patient, female is on one to two milligrams of transdermal or transmucosal testosterone and somewhere between ten and twenty-five milligrams of DHEA, again transdermal or transmucosal.
Dr. Lynne Mielke: So, again, a small percentage cannot tolerate very much because of acne or a skin … or breakouts. But that’s pretty rare. And again, the saw palmetto products usually help, again, a small percentage that just, for whatever reason, can’t tolerate it at all and you have to stop it in those cases. But, for most patients, the vast majority, they tolerate it and they feel much better. So, that’s the baseline.
And, then, if they’re still struggling, then my psychiatric background comes in handy here. We talk about self-esteem issues, body image issues. So many women feel like they’re just not pretty enough, thin enough, perfect enough. And so, they don’t like to get naked because of that. So, we have to talk about that.
And then, if there’s any kind of conflict in their relationship, that’s a biggie. But I find that for women, one of the biggest issues of all, even after you’ve addressed all of these other problems is that … and I usually say to my female patients, I say look, women are multitaskers. We are doing a thousand things in our head all day long. And, many women just cannot shut off that to do list in order to get into a sexual encounter, if you will. So I counsel women and I say, look, you have to get your head in the game.
And that is actually a very important step that a lot of women don’t do. They just expect themselves to be able to be running around the house taking care of the kids and their laundry or whatever. And then, boom, shift gears and they’re ready. And, I’m like, you have to take some time. You have to be relaxed. You have to think sexual thoughts. So I actually tell women, you have to intentionally shut down that to do list and intentionally start thinking sexual thoughts. And I will tell women, use sexual fantasy. So I say, look, men do this all the time. Men just naturally do it. Women have to actually be coached, frequently to use sexual fantasy to get their brain engaged.
And so I even recommend, sometimes, reading a book, My Secret Garden by Nancy Friday. It’s a classic book. It was actually recommended reading in my psychiatry residency program years ago. And it’s a psychologist who actually cataloged, she interviewed and cataloged a bunch of women’s sexual fantasies. So what that does, if women read that book … first of all, it gives them permission to have sexual fantasies. And it can also give them ideas of different kinds of sexual fantasies. And women have to be given permission, like, it’s okay. It’s sort of like, I tell them, you don’t have to necessarily be thinking about your partner every second. If something else is what is arousing to you, do that.
So, it’s very important to give women that permission and to even coach them with that. And, I coach women and encourage women to masturbate. I find so many women say, oh, I just can’t have sex because my partner isn’t willing or available or I don’t have a partner or whatever. And I say, look, you don’t have to depend on a partner for orgasms. And you should have orgasms. They’re good for you. They release all kinds of positive chemicals in your life. And I say, when you’re young and healthy, people want to have sex. They want to have orgasms. And I say, when you get older … first of all, when those hormones go away, that part of your brain just falls asleep. It goes to sleep. I said, it’s not dead, it just needs to be reawakened. And hormones do that. But, sometimes that’s not enough. I say, you have to know how to give yourself an orgasm before you can have, expect, a partner to do that for you.
So, it’s very important to coach women on that kind of thing. And I actually say, I don’t have any good science behind this. But, I believe that when people stop having orgasms, that is a signal to your body that something’s wrong. That you’re ill. Because, it is one of the first things that goes out the window when people get sick.
Dr. Kara Fitzgerald: Yes.
Dr. Lynne Mielke: So, if someone has a good libido, that, to me, is a sign of health. Health and well being. So, I track that with people and encourage them and have them try to have several orgasms per week.
Dr. Kara Fitzgerald: Wow. Good.
Dr. Lynne Mielke: I actually wrote a … I wrote a blog about that on my website. Because I talk to people about that.
Dr. Kara Fitzgerald: It’s just a really under addressed area and I appreciate you so much bringing it to New Frontiers. Important conversation. And if you send me a link to your blog, we’ll put it in the show notes. I’m sure that folks want to hear … read it. So what percentage of your practice, now, is doing anti-aging/bioidentical hormone replacement?
Dr. Lynne Mielke: Well, like I said, I do have a part of my practice that is still autistic kids, believe it or not. It’s just like this weird thing where we treat autistic kids and then anti-aging and wellness and hormones and this and that. So, it’s a strange combination, if you will. But it’s all integrative functional medicine. All of it.
A lot of people are afraid to take hormones. They’ve heard so many bad things or whatever. And I actually tell people that I consider bioidentical hormone replacement, I consider hormones like a nutrient to the cells. It’s like it’s bad to be low in minerals and vitamins. It’s bad to low in hormones. So many women think that menopause just means you have hot flashes for a little while and it goes away and you’re done with menopause. I tell them, no, that’s not what it means at all. It’s not about hot flashes. It’s about being hormone deficient for the rest of your life. That is bad. This is like … this is why … it’s one of the main reasons why women get Alzheimer’s more than men. Because women lose their hormones and men don’t necessarily lose their hormones. Some men do, but not all men do.
And if you read the book, The End of Alzheimer’s, by Bredesen, one of the big interventions to prevent Alzheimer’s is to take bioidentical hormones.
Dr. Kara Fitzgerald: Right. Right. What about concerns around … so, the big concern, obviously, is promoting cancer with these growth hormones. So how do you assure you’re not?
Dr. Lynne Mielke: Well, what I always say is that … I like to use a lot of analogies when I’m explaining things to patients. So I say, water is essential for your health. But too much water can kill you. Okay? So, it’s like estrogen. It’s really important for your brain, your bones, your heart, your libido, your skin, you name it. Essentially every part of your body; right? But, too much estrogen is really bad and having that gas pedal with no brakes is really bad. I said, you wouldn’t drive a car with a gas pedal and no brakes. So I say, I will not even prescribe estrogen unless you’re willing to take progesterone and monitor and make sure that those levels are adequate.
So, I always say, if you take the right amount of a bioidentical hormone and it’s properly balanced the way nature intended and you can cycle it … progesterone, for a number of women, I cycle them on and off. And for others, I do it all month. But I usually recommend that they do take one to three days off per month.
Dr. Kara Fitzgerald: Okay. And this is for … I mean, this is in your post-menopausal women?
Dr. Lynne Mielke: Yes. Yeah. So, younger premenopausal women, I start them on progesterone. Again, any time between 35 and 45, they need to start taking progesterone. And then, depending on how their labs come out, they also may need to add the estrogen later. Closer to 50, usually, but you never know, depending on the patient. I have some 55 year old women who still have estrogen and are still having periods on their own. But they’re getting progesterone, testosterone, DHEA, maybe, depending on what they need. And it’s, again, depending on that urine test.
It’s just important to get all these hormones balanced. I always say, I know that in this country estrogen is listed as a carcinogen. And I find that just appalling. I say, do you honestly believe that millions of years of evolution, higher power, whatever you want to call it, would intentionally design a hormone for the human race that would intentionally give us cancer?
Dr. Kara Fitzgerald: Right.
Dr. Lynne Mielke: It makes no sense for the survival of the species whatsoever. The reason women are cut off at middle age is because it’s mother nature, again, in its wisdom, knew that women should not be having babies at 70. So, that is why men get to keep their hormones and women don’t. It’s because we’re the incubators. So, anyway, it’s like you just need to be able to give hormones at the right dose, properly balanced, take a break every month or so to give your … I say it’s sort of like rebooting your computer. It’s resensitizing your receptors. It’s giving your body a few days off, and then get back on.
People say, how long should I continue to take it? And I say, how long do you want to feel better?
Dr. Kara Fitzgerald: And so, that’s how you’re dosing in your post-menopausal. And then, in your premenopausal, I’m assuming you’re giving them a bigger chunk, off, obviously, so they can still have a period. Anybody who’s still menstruating?
Dr. Lynne Mielke: Yeah. I mean, in the premenopausal, I’m probably not giving them estrogen at all. So I’m cycling their progesterone like days 12 to 25. And if they’re in the younger premenopausal, I’ll go with the 100 mg per gram progesterone. As they approach closer to 50, I increase it to the 200 mg per gram. So topi-click map, basically, one click is a quarter of a gram. So I always tell people take the milligrams on the label, divide by four, and that’s what you’re getting in one click. So, it helps them know what they’re actually getting.
Dr. Kara Fitzgerald: That’s … you’ve obviously been doing this for a while and you transitioned in from psychiatry. And, I have a clinical development program, so physicians are tracking what we’re doing in practice and we invite them in to observe virtually. And it’s really been pretty exciting. One of the biggest, biggest questions is, how do you make the transition? Especially physicians who’ve been practicing in a supported clinic setting and the jump to hanging out their own shingle and just how they go about managing that is a big one and it’s daunting and it’s really anxiety provoking. But you obviously did it. You did a great job.
Give me some thoughts on your journey there and any pearls.
Dr. Lynne Mielke: Yeah. It isn’t easy. I mean, I’m not going to sugarcoat it. You have to have good staff. I mean, you need people who can do your books and help manage your practice. One of the big things that you have to do when you switch into a private self-pay only kind of practice, is you suddenly have to think about marketing. This is something that traditional doctors don’t really have to think about very much. So, making sure you’ve got that website that covers everything you do. And then, maybe giving talks in the community. I actually did a lot of that when I was first starting my practice. And, also, I wrote a bunch of PowerPoint presentations and went to health fairs and this and that.
And then, eventually, as the practice grew, now, I don’t really have to do that anymore. It’s not that I don’t want to, I actually enjoyed doing it. But, it is time consuming. But now, it’s essentially people find us through the website. But a lot of it is just self-referral from other patients. Somebody will come in and then they’ll refer their entire extended family. So, that’s how the practice is growing is by that.
Dr. Kara Fitzgerald: But, for a while, you toggled between your conventional practice and building your integrated practice.
Dr. Lynne Mielke: Yeah. When I first started. Yeah. I would say six months to a year, I just sort of, I actually sort of kept my old patients. And, I told them all that I’m making this transition and I can refer you to another psychiatrist. But many of them followed me into the new practice. And then, I just sort of increased the one and decreased the other over time. And the transition just worked. I don’t know exactly how to explain it. But, keeping some of the old practice methods while you’re starting the new one. Even if you just do, like, two days a week here, two days a week there, something like that. It worked out.
Dr. Kara Fitzgerald: Now, you mentioned earlier that you blogged. And we’ll actually link to your website, also, not just the blog, we’ll just link over to your website on the show notes … as do I and I have been for years. And Chris Kresser, I interviewed him last year. And, he talked about building his practice around blogging. That was a communication mode for him. That has been helpful for you; would you say?
Dr. Lynne Mielke: Yeah. I mean, I’m probably not using it as a primary thing. But, to me, I like to blog about a topic that I find myself having to talk to patients about over and over and over. If there’s something that I want to be able to expand on and often don’t have time in the appointment to go through this long explanation, I’ll frequently write a blog about that. And then I’ll say, okay, read my blog on X. And I also assign a lot of books. I really recommend that. I tell my patients, read this book, read this book, read this book. Because, again, it’s so difficult in an appointment to be able to do the level of explanation that you need to. I’ve even had patients who were on the fence about bioidentical hormones, for example, and I’m explaining all the health benefits and this and that.
Finally I say, read Suzanne Summers. And I’ll say, Age List, I’m Too Young For This, The Sexy Years. Those are some of her better hormone books. And, I say she’s not a blond bimbo. She knows what she’s talking about. She knows more about bioidentical hormones that most doctors. And I will tell the patients … her writing style is very engaging and she explains it well. It’s not like I agree with a hundred percent of what she says, but a lot. And so I tell people to read that. And they come back and go wow, yeah. Now I get it.
Dr. Kara Fitzgerald: Yeah. Good.
Dr. Lynne Mielke: I just find that to be really a helpful tool. I have a whole book shelf full of integrative health books. And I say, read this one. And they’ll take a picture of it and they’ll read it. It’s very … it’s such an important part of our job as integrative practitioners, to educate or patients. And nutrition books, hormone books, all of it.
Dr. Kara Fitzgerald: Are you doing the nutrition prescription with your patients? Or do you have support staff? And if you do, who’s helping you out in this arena?
Dr. Lynne Mielke: I actually don’t. I used to have a nutritionist on staff and I just ended up not being able to maintain that. But I usually just recommend people read these various books. One of my favorites is It Starts With Food by Hartwig. It’s a really good overall nutrition book. I like for patients with any kind of addictive food problem, I recommend The Bright Line Eating Book. Other for autoimmune disorders and all kinds of gut … I recommend The Plant Paradox book. So I have a lot of … a paleo book, I recommend all those, those kind of things. Ketogenic books.
And I try to customize my own dietary … depending on the patient and their health problems. And I recommend a lot of intermittent fasting for people. So, I basically customize the nutritional recommendations, give them the resources, and if they need help, I can refer them to a nutritionist.
Dr. Kara Fitzgerald: Mm-hmm (affirmative). Got it.
Dr. Lynne Mielke: Most people can do it on their own if you give them the right advice.
Dr. Kara Fitzgerald: Nice. So you keep a library in house and just pull out your books and say, get this one, read this one, and that’s part of your dietary prescription? That’s great. I know a lot of new … we have a pretty robust nutrition team here. We actually have a nutrition internship program. But, a lot of clinicians transitioning in, and certainly me, in the beginning of my years when I first started my practice, I was doing it all on my own. And it’s just a great idea to have a good resource of books. There are so many good therapeutic nutrition books out there now.
Dr. Lynne Mielke: Absolutely, yeah.
Dr. Kara Fitzgerald: Well, listen, Dr. Mielke, it was wonderful talking to you. I think you’ve given us a lot of pearls. And it’s just really nice for a change for me to actually talk to a clinician who’s in the trenches doing this day in and day out, particularly somebody with your breadth of experience and coming from the DAN conference era and taking a leap into doing anti-aging stuff. I know you’ve just got a wealth of experience. And I think our listeners are going to …
Dr. Lynne Mielke: It’s such a rewarding way to practice. When you see those patients getting better. And integrative medicine is just so obviously the right way to go.
Dr. Kara Fitzgerald: Yeah. Agreed. Okay, that sounds like a good place to end. Thank you so much.
Dr. Lynne Mielke: Oh, thank you.