Low libido, testosterone, estrogen and HRT with Jennifer Gularson, PA-C

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This week, Jennifer Gularson joins me to talk about perimenopause, menopause, and low libido, along with what’s actually happening in the body during this transition. We break down how stress, sleep, blood sugar, under-fueling, and hormone shifts can all impact libido, mood, cycles, and energy levels. We also discuss why so many women feel dismissed when symptoms start showing up, how testosterone, estrogen, and progesterone change through perimenopause and menopause, and the evolving conversation around hormone replacement therapy, healthy aging, and longevity so women can better understand what their body may actually need.

KEY TAKEAWAYS:
• Low libido is rarely just one thing
• Stress hormones affect sex hormones
• Perimenopause can feel unpredictable
• Estrogen impacts long-term health
• Lifestyle habits still matter deeply

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ABOUT GUEST:
Jennifer Gularson, PA-C, IFMCP is a board-certified Physician Assistant and functional medicine practitioner specializing in perimenopause, menopause, hormone therapy, and women’s midlife health. With over 20 years of clinical experience, she focuses on personalized, science-based care to support longevity, metabolic health, and overall wellness for women navigating hormonal changes. 

WHERE TO FIND GUEST:
Website: https://www.yourbestlifewithjennifer.com/ 
Instagram: https://www.instagram.com/jennifergularson/

NUTRITION PHILOSOPHY OF LESS STRESSED LIFE:
🍽️ Over restriction is dead
🥑 Whole food is soul food and fed is best
🔄 Sustainable, synergistic nutrition is in (the opposite of whack-a-mole supplementation & supplement graveyards)
🤝 You don’t have to figure it out alone
❤️ Do your best and leave the rest

WHERE TO FIND CHRISTA:
Website: https://www.christabiegler.com/
Instagram: @anti.inflammatory.nutritionist
Podcast Instagram: @lessstressedlife
YouTube: https://www.youtube.com/@lessstressedlife
More Links + Quizzes: https://www.christabiegler.com/links
Protocols: https://www.christabiegler.com/protocolshop

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TRANSCRIPT:

[00:00:00] Jennifer Gularson, PA-C: we know that there are long-term chronic diseases, diabetes, osteoporosis, dementia, cardiovascular disease. All of those are because of the lack of estrogen and other things.

[00:00:12] Christa Biegler, RD: I'm your host, Christa Biegler, and I'm going to guess we have at least one thing in common, that we're both in pursuit of a less stressed life. On this show, I'll be interviewing experts and sharing clinical pearls from my years of practice to support high-performing, health-savvy women in pursuit of abundance and a less stressed life.

One of my beliefs is that we always have options for getting the results we want, so let's see what's out there together.

All right, today on the Less Stressed Life, we have Jennifer Gularson, who's a physician's assistant. I think that's how we say PA-C. I don't know what the C is, means. It's- 

[00:01:10] Jennifer Gularson, PA-C: Correct. It's a certified, yep ... 

[00:01:11] Christa Biegler, RD: certified physician's assistant Or certifiable. All right, perfect. She's a leading expert in women's midlife health, functional medicine, longevity, and natural aesthetic enhancement.

She's a board certified physician's assistant and one of fewer than 2,000 IFM, which is Institute of Functional Medicine, certified practitioners worldwide, and she brings over 20 years of clinical experience and advanced training in BHRT, peptide therapy, metabolic optimization, and evidence-based longevity care.

At the Osteopathic Center for Healing, Jennifer is known for her clear science-based approach to perimenopause, menopause, and complex chronic conditions. She's a trusted clinician for high-achieving women seeking personalized hormone therapy, integrated wellness strategies, and natural identity preserving aesthetic results.

Welcome to the show, Jennifer. 

[00:01:56] Jennifer Gularson, PA-C: Thank you so much. Glad to be here. 

[00:01:58] Christa Biegler, RD: Yeah. All right, It feels to me that perimenopause and menopause is a hot topic, but I think that, there's been integrative and alternative medicine forever, but the functional medicine space, the leaders in functional medicine are aging, and so I feel like we're seeing an anti-aging movement a little bit because the people doing the work are aging in general.

But you're in this very hot topic, but you're in this other niche of... And the reason you're here is because I was telling you before I hit record that the thing that clients rate the most on their forms is low libido. And so we're covering a little bit of low libido today, and I'm really curious how you got to talking about that all the time and why you're on podcasts talking about libido.

[00:02:47] Jennifer Gularson, PA-C: Okay. So yes, I'm in that perimenopause space and physically treating patients, but I am also in perimenopause. I guess technically I'm in menopause. I think it's fun because women, menopause is technically 365 days without a period. But I'm treating so many women in perimenopause that I don't know that's gonna be this mythical, magical moment of 365 days because we're gonna have some strange things happen because everybody's on hormones now, and patch shortages.

Can I come to North Dakota and, South Dakota ... yeah, and get some patches there? Maybe they have some there. 

[00:03:22] Christa Biegler, RD: Yeah, 

[00:03:22] Jennifer Gularson, PA-C: maybe. South Dakota. So how I ended up here, I was fortunate enough to l- to work in a med spa where the owner was going through menopause herself. This was back in 2008. So I've been doing hormone replacement for a really long time, and been interested in it.

I think people like me because I'm honest and I come from a place of no judgment. So when they say, "I don't know if it's me, I don't know if it's my partner, but I just don't feel like having sex anymore," we try to get to the root cause of why that's happening. And we'll go through, all the different things that it possibly could be.

But I just found myself here because no one else was doing it, and I feel passionate about helping women through this time because it was rough for me. And I just had the luxury of having hundreds of patients come through my office, and I get a lot of stories, and the stories are very much the same, but they, everyone feels alone.

[00:04:16] Christa Biegler, RD: Yeah. And 

[00:04:17] Jennifer Gularson, PA-C: that's one thing I'd like to s- point out. I'm like, "You're not the only one." And they say, "I'm not the only one?" And I think the reason why it rates so high on your intake, and it does on my intake, I'm on a scale of one to five, and a lot of times it's four or five, is because no one else is asking that.

And they're like, "Oh my gosh, here's my opportunity." 

[00:04:34] Christa Biegler, RD: Yeah, for sure. Okay, so let's talk about... That's awesome, and my goodness, we're up to 18 years of hormone replacement therapy. So you've seen the whole gamut, because it's a Wild West still, I feel. Yeah. It's like a trial and error in general, and that's a whole nother topic.

I'll attempt my best. I don't know if we'll do a good job with this or not. I'll attempt my best to stay on this topic. So let's talk about low libido. What's happening? Why is it becoming more prevalent? What's actually happening in the body? 

[00:05:06] Jennifer Gularson, PA-C: So as we age, and women are becoming more substantial in the workforce or even having more kids or just being busy, kids have More activities.

So I'm just finding more stressed women. So I would say stress has a lot to do with it, and being overextended lack of sleep, because at the end of the day, when it's your time, so many times they're like that's the only time I have is the kids are asleep. My partner's doing what they're doing.

It's my time." And then everybody goes to sleep, and then they're up till 11:00, 12:00, 1:00 scrolling or reading or knitting or doing what they... it's their time., Your day is filled with a lot of stress, which can affect sleep, which can affect your mood, which can affect your appetite and what you're choosing to eat the next morning.

And it can also steal the stress of not sleeping and not digesting well can steal, as cortisol will increase, and then your sexual hormones will decrease. But the, women are just have a lot on their plate. They have a lot domestically, keeping track of the kids, the house, and stuff, and then a career, add a career onto that.

The busyness doesn't help. And I'm here in the DC area, and it's like a badge of honor who has the most stress. 

[00:06:18] Christa Biegler, RD: Yeah. 

[00:06:18] Jennifer Gularson, PA-C: So that certainly is happening all when your hormones start to wane anyway. So you have all this stress mounted on top of you when your ovaries are like, "Yeah, I think I'm gonna take a break here," or, "Every other cycle I'm just gonna take a break."

[00:06:33] Christa Biegler, RD: Yeah. You're really saying what I have been seeing as well with people. And just like you, I think that we have these high-achieving women who have a physical symptom. They're coming in for probably other symptoms, right? They have physical symptoms, so they would go to a practitioner for physical solutions.

And stress psychologically, whether it's perceived or real or however we want to talk about it... one of my stresses over the last three years was as I got busier and busier, I was less active in a good way, right? I was getting probably 3,000 steps. But this is just an obscure random thing, right?

But it's like I don't think I was unique there, right? Because I was also going through these things I could've said all the same things, where my body is changing, but everything stayed the same. But if I was really honest with myself, the stress was higher because the workload was much higher in general.

And so- I talk, I think about this kind of stuff all the time on how your stress hormones are the foundation before anything else will work. Everyone wants better progesterone but it's a epidemic that's not great because if your body doesn't have enough resources, which is exactly what you're describing, is as stress increases, as our sleep decreases,

If we're not fueling, which takes so dang much intentionality- Oh, my gosh. ... it's annoying. If we're under-fueled in any way, all of these things are gonna deplete us. Your body doesn't really have the resources to make sex hormones in general, right? Progesterone, estrogen, testosterone. 

[00:08:00] Jennifer Gularson, PA-C: It's just trying to survive.

Yes. 

[00:08:02] Christa Biegler, RD: Yeah. And unfortunately, it looks like that. I don't do too much sex hormone testing, not a lot. I may support someone in getting that testing done. But when I was doing more of it, and I used Dutch testing initially, I don't know what you, if you use a little bit of both of different things.

When I would see low testosterone... So first of all, would you also consider that testosterone should be low if there's a physical... That would be the main hormone I would think of. That would be the main sex hormone I would think of with low libido. So do you see do you feel like that overlaps, or do you feel like you were seeing more of these, other factors that we can control outside of testosterone.

Because when I would see low testosterone, there was usually some kind of long-term chronic stressor anyway, but that long-term chronic stressor could have been a trauma event, it could have been IVF, it could have been something really significant. It could have been mold exposure. It could have been something really hard on the body that's also really depleting.

And so I'm curious about when you have people complaining of libido, what you do first for a workup and how often you were seeing testosterone as one of the root causes, or if you feel like it's really a myriad of several markers. Do you see... When people come in and they want an answer, do you see it on labs or do you not see it on labs is part of the question.

[00:09:16] Jennifer Gularson, PA-C: Ooh, yes and no. And it's hard because sometimes they come in wanting labs, which I'm totally fine to do. 

But then I also explain this is one snapshot in one day at one second of the day of your cycle. So I go a lot on symptoms. So one of the things that I recommend is people take good notes on their symptoms, use like a period tracker or something and just come in with a lot of data 'cause then we can sort through and be like, "Oh yeah, looks like this time you didn't ovulate," or whatever.

But yes, I always look at testosterone. The frustrating thing is, and you've probably seen, like the labs are skewed low. My labs here are usually between four and 40 serum testosterone, and then nobody ever does free testosterone. That's more important. And then your free testosterone can be zero.

Normal is zero to like 4.5. And I'm sorry, but no free testosterone is not, it's not acceptable for a man. Why is it acceptable for a woman? So a lot of times it's explaining that, yes, in this instance when we did your blood work, your testosterone was 20 free, in a free of .9. I understand that's normal, but it's not optimal, so explaining those ranges.

Women tend to feel a little bit better between 50 and 100 total and around three free testosterone. So getting those numbers up a little bit. And maybe, the standard dose is five grams a day. That's become the standard dose, but as there's no FDA-approved form of testosterone or consensus on how much we should be giving them.

So I use compounding, I use injections, I do pellets. I do it all depending on the patient. But monitoring those levels really does help. But I generally between 50 and 100 for total and a free around three- Patients tend to feel better. However, I don't feel like it's the magic bullet the answer for everybody.

It's multi- For sure ... factorial. And I think low estrogen actually plays a role too, because if you look at our cycles and where our estrogen and our testosterone is during that cycle, right at ovulation you do get that bump in testosterone, and you get that little bump of estrogen to drive you to wanna have sex and procreate.

Making sure your estrogen is adequate too, not only for your brain but for your vaginal area too. So- ... using vaginal estrogen down there and, and- Yeah ... testosterone even too is good. 

[00:11:42] Christa Biegler, RD: Yeah. I wanna get a little bit nerdy. I wanna just b- dive into a few th- Yeah ... of the things you said about testosterone, then I'll go to estrogen next, so this is great.

So first of all, if the reference range for free testosterone is zero to 4.5 why do you think that they even used zero? Usually- ... the reference ranges come from what we see go through the lab, but this makes me think that there's some kind of something goofy, or this is one of those outdated things where research wasn't done on women, so a couple things. Why is the reference range zero in the first place? Do you know anything about that? And then why is free testosterone better than serum? And just tell us a little bit about the difference between those two. 

[00:12:22] Jennifer Gularson, PA-C: Yes. So first s- serum testosterone, that's typically what most people get.

It is bound, it's basically bound in your serum by albumin and sex hormone binding globulin. The analogy I like to use is that's money in the bank. That's available to you, but you gotta go through some steps to get to it. You gotta go to the bank, you gotta withdraw. The free testosterone is actually free hormone in your blood measured that you can use.

And if you have certain things like high sex hormone binding globulin because you're insulin resistant, or you're taking birth control pills, or you're taking oral estrogen, that's gonna be high and it's gonna bound, it's gonna bind more of your testosterone, and you're not gonna be able to use it. So I've had some women with two, 200 serum, but they only had two free because of

[00:13:13] Christa Biegler, RD: oh

all the other stuff that's there ... so dramatic. Yeah. 

Yeah. What were some 

[00:13:15] Jennifer Gularson, PA-C: of 

[00:13:15] Christa Biegler, RD: the reasons that it was u- so taking oral estrogen would bind testosterone. What were some of the other reasons? 

[00:13:20] Jennifer Gularson, PA-C: So taking oral estrogen increases sex hormone binding globulin. So sex hormone binding globulin does that. It binds to sex hormones.

Yeah. So it's gonna take things out of commission. Taking birth control pills, again, increases sex hormone binding globulin, and then also insulin resistance- ... and metabolic syndrome 

[00:13:40] Christa Biegler, RD: Yeah. This is really interesting because with that information, it would make a lot of sense that you could see one of those testosterones, like the money in the bank, the serum testosterone looking high, but the free testosterone not being very good.

And so what that could look like is, I wonder, 'cause there's a couple pathways that testosterone can go down as well, right? Alpha, beta, I think. And so depending on which way it goes, I think it's more likely that you might have, male pattern hair growth. So chin hair on your chin. Does...

Let's actually talk about that today, too- ... 'cause no one wants any more hair on their chin as a woman. Also things that are not talked about. So hair on the chin, breasts, belly button, et cetera, so you might have symptoms of that where I wonder if both can exist, where you also may struggle with maybe workout recovery, right?

'Cause these high-achieving women, of course they're gonna be doing workouts, right? 'Cause it's like checking 

[00:14:32] Jennifer Gularson, PA-C: a 

[00:14:32] Christa Biegler, RD: box- Yes ... typically. So is that possible, that you're gonna see these things that seem at odds really, right? 

[00:14:39] Jennifer Gularson, PA-C: Correct, yes. Yeah, they might be saying like I'm taking it, but I'm not feeling anything.

I'm not making gains in the gym. It's taking me hard- it's longer to recover." Or yeah, even the libido p- the libido part. 

[00:14:52] Christa Biegler, RD: The thing that, that's interesting about testosterone, which is why I wanted to dig into it a little bit, is I would maybe see it low on testing. The herbal recommendations for testosterone, tribulus, 750 milligrams, BID, were never really effective.

And testosterone is outside of my scope of practice, But when I would see it really low, I would try to refer out. But the challenge is finding someone who knows what they're doing whatsoever with hormone replacement therapy for that client and, what other factors are being accounted for as well.

So for example, before we leave this testosterone conversation and go on to estrogen and some of the other possibility things, then some of the other lifestyle factors, there is... as you said, you've done... You have experience with everything, pellets, patches, et cetera. Now, some of the mentors I've had over the years, I feel like pellets are very common for testosterone, but some of the mentors I've had over the years aren't big fans of pellets because you just guess at a dosage, and then you're stuck with it until you wear off.

So what are your thoughts about... I think the simplest way to ask this question is since you have 18 years of experience with hormone replacement therapy, what have you landed on now generally, or is it still a combination of different things? 

[00:16:07] Jennifer Gularson, PA-C: Yeah I like, you can't be the be-it, end-all for everybody.

S- and I... Nobody's the same. I offer all of them, and- Rarely do, unless they come in wanting pellets, rarely for women do I start at pellets. And this is to say back in, when we first started, that's primarily what we were doing because the compounding pharmacies hadn't gotten caught up and really

We were doing a lot more pellets. And we would say, "Oh my gosh, you're so low. Here. Here, take a lot of testosterone." And they would feel great for that placement because, all those receptors are ready and waiting for this testosterone because it's so low. You flood their system, they feel great, they get really horny, they start humping everything.

And then your second placement is not... And then all those receptors down regulate because they've been satisfied, and then they they go for their second placement. They're like, "I just didn't feel the same kick." So then I started backing off and being like, "Okay, we're gonna go slow and elevate as we go."

The pellets get a bad rap because they're expensive. They're a very good way to bring, generate cash into a clinic if you're not doing it with the best of intentions. That's... And then also, yes, if you place a pellet it's really hard and difficult to take out. They're tiny. They're almost like a piece of arborio rice or just like a little rice kernel.

So to fish that out would be almost impossible. So you just have to wait it out, about three to five months. Which is 

[00:17:38] Christa Biegler, RD: pretty long. 

[00:17:39] Jennifer Gularson, PA-C: Yes. And I was seeing in some clinics is that they're just over-treating or they don't feel comfortable doing the estrogen so they're only giving a testosterone, hoping they will convert and aromatize it into estrogen, which I feel like doesn't work very well at all.

But for the right patient, for somebody who can't inject or won't, doesn't wanna inject, they can't be compliant with their creams they just feel like they don't... just, they just wanna put it in and forget it. Men are really great ... Not to bash men, for men to do, put creams on every day, they just don't like it.

So they... And then they get needle fatigue. So I like offering all the forms. And then that's not to say that I don't have somebody do pellets for six, nine months and then come back and do creams for a little while and then say, "Oh, I think it was better." I think it's great for, to offer i- it to everybody.

And then I have clients that, some of them, I have a patient that has a birth defect and she doesn't have the use of her arms, so how is she supposed to rub cream and put patches on? The pellets are actually a really good option for her. I would say it's about 10 to 15% of my practice, but for the right person.

And I'm pretty conservative, so I'm doing it so that they last about three to four months versus jacking them up and letting them ride for six months and I'll- Particularly like that 

[00:18:54] Christa Biegler, RD: I loved hearing your perspective, and that story about your client cannot use your arms. How appropriate that you have all of these...

I think this is- 

[00:19:00] Jennifer Gularson, PA-C: Yeah ... 

[00:19:01] Christa Biegler, RD: very good storytelling. But where are the pellets placed? And then when we are over, when you're overdoing the pellets and after that initial receptor site is satisfied, what are some of the negative results if people are on too much testosterone? 

[00:19:17] Jennifer Gularson, PA-C: So the p- pellets are placed right in the subcutaneous fat, in your rump, basically.

So it's funny because I'm a Real Housewives crazy person 'cause it, it helps me decompress. Kyle Richards was talking about how she gets pellets, and I think she was on a podcast, and she said, "Where do they put them?" And she said, "In my butt," and that's technically correct. It's in your- 

Butt muscle, like in, in the little fat pad on your hip. For some men who have no butt, if they have a long back with a crack I will put them in a little bit higher up in their back fat. It just needs to go into subcutaneous fat. The fact that you're doing a s- it's technically a surgical a- administration.

You're using a trocar and going underneath the skin. You do put a little nick in the skin. It's real small, and you butterfly it back, so you are left with a little scar. Sometimes you can get a little indentation where the trocar goes through. In the site itself it could get infected so that's locally.

But systemically, if your preference is to break down testosterone in the alpha pathway, you might experience some of that, the hair loss acne, oily, greasy skin and then hair growth other places. Typically not nipple hair and on your abdomen. Usually it's a little bit of the facial hair.

And it's so interesting because dihydrotestosterone, which is the breakdown of testosterone through that alpha pathway, is responsible for hair loss on your head but hair growth on your face. It just shows there's different receptors in the different hair follicles, which is crazy. But that's why you see a lot of men with full beards but

they're bald here, full beards, and lots of hair on their chest. So those, the acne can be pretty significant. And then for some women if the h- DHT is a little bit too high, it can cause a little bit of agitation. So You can block that with the five alpha receptor blockers.

Propecia finasteride, and saw palmetto is a great one. I like using pumpkin seed extract. It just all depends on, Or spironolactone, that's the other one that I use. It just all depends on who, if they wanna start out with a little bit of herbs and or then go to a medication to do that.

It just... And I tell them, it doesn't take testosterone out of the equation, it just changes the way you break it down into an easier form for you to get rid of so that you don't get the acne and the hair growth. 

[00:21:45] Christa Biegler, RD: Yeah. It's tricky. I think we're getting just into a corner of this conversation right now.

Okay. And hopefully listeners can understand that there's a lot to it, right? Not surprisingly. And I think one of the first things you said was, if people could just come in with data, they could jump off from a better place. And I say the same thing. If you could just do a bullet point list of all the things, your clinician can do such a better job for you.

They'll be able to find so many more patterns for you that you weren't able to see. So let's talk a little bit about estrogen. You said sometimes clinics i thought it was great you just called out that sometimes people use this because it's, a part of a money thing with clin- and all of this is relevant.

Everything is relevant. It makes the job a little bit harder, right? Because you, your option is to educate really well. Yeah ... okay, so some people are dosing up testosterone because they're afraid to give estrogen, which there's some discussion about oral estrogen versus topical estrogen, so let's talk about that.

And because they're relying or they're hoping that giving extra testosterone that it will change its hat and aromatize and become estrogen. Yes, which, sometimes we do not want that as well. Which makes sense. No. It's not everyone's gonna do that. So- Yeah ... so let's talk a little bit about being afraid of dosing estrogen.

This was actually pretty hot in the news, I think, over the last year or two. I don't know, the years are all blending together. Let's talk about estrogen, and then also there's a conversation around in perimenopause we have a surge of estrogen as well, right? I think, I don't know who it is, Aviva Romm or Lara Briden calls it second pu- someone calls it second puberty.

[00:23:21] Jennifer Gularson, PA-C: Second puberty. 

[00:23:21] Christa Biegler, RD: Yeah. Yeah. So let's talk a little bit about estrogen, its role in low libido. Why is it... I always think of testosterone being part of the physical libido regulator, but let's talk about why estrogen makes a difference in libido, and let's talk about how it fluctuates through these years, perimenopause, menopause, et cetera, and then what it looks like when you're supporting estrogen.

[00:23:44] Jennifer Gularson, PA-C: I think we're at an interesting time. Not only, give me a woman who hasn't had a cycle in two years, she's easy. You just throw a, give her a patch, give her some progesterone, testosterone, they're good. This perimenopause is a whole nother Huh. It's a lot. And first of all, women are being gaslit by some of their clinicians by saying perimenopause is made up and, you really don't need anything.

You're still cycling. Why do you need help? You're obviously a thing. And to my... I will admit that I was saying those things several years ago. Not saying that perimenopause didn't a- didn't exist. More that should I be treating you because, should I be giving you hormone replacement?

Obviously you're cycling. But as I was explaining to a patient today, your eggs get lazy. So in our 30s, 40s, we have 10... We're down to 10% of what we used to have, and sometimes it's cycle by cycle. So this particular patient was noticing her cycles were shorter and her periods were heavier, and that definitely had changed in the last nine months.

So I'm like, "Okay, so you're either not ovulating, so your ovaries are not producing an egg, or it's trying and there's just not enough or they're it's just lazy." So this up and down thing that happens, and my philosophy is that in perimenopause, I'm providing a safety net for you because your estrogen and progesterone or it can go up and down and up and down.

And that craziness, especially when we were doing it back in when we were 13, 14 and before we got our regular cycles the erraticism of, if that's a word, of the up and down of the estrogen really does cause the symptoms, and then the lack thereof, progesterone causes the symptoms.

So what I'm doing by giving a very low dose in the grand scheme of things of estrogen, I'm providing hey, you're not gonna go below this number, so at least you have some. Because when you go so low you get symptomatic, it signals your brain, which stimulates FSH your next cycle to go really high.

So then it's your FSH goes higher, so then that res- that stimulates your ovaries even more to make more estrogen, build up your endometrium, and then you may or may not get an egg. And even if you do, that shell that's left over might not produce enough progesterone to balance out that really high estrogen.

You get another heavy period, you get clots, you get a closer cycle. Or That really high estrogen produced the best egg of that lot. The progesterone is great, and you had an actually normal period. But then the next time, it, your FSH is gonna go down 'cause it's like, "Okay, I did it." It's gonna go down, then your estrogen doesn't go, make the egg again.

So then you can see you can have a great period one time, and then one cycle, and then two bad cycles, and then finally it gets back on board. So you get these sputtering outs, and either you have longer periods where you skip a period here and there and then you have a bad one, and then... Or you have a heavy one, light one.

And everybody's different. That's the problem. It's not like everybody follows the same path. So what, by providing in perimenopause some oral progesterone, maybe even just the second half of the cycle, or you're taking 100 milligrams first half of the cycle, 200 milligrams mid-cycle, and 300 milligrams the last half of the cycle.

Just trying to figure out and giving women the power to say, last night I slept like crap, and I'm really anxious. I'm gonna go to 200 milligrams next, tomorrow night and just see where it is," or, "I took 200, and I woke up a little groggy. I'll just do 100. Plus, I have this patch that's making it so that I don't have the hot flashes, and then I got a little testosterone."

So the erraticism of the, of those and the ups and downs and the swings, yep it's back to when we started it. We're going through that second phase. 

[00:27:36] Christa Biegler, RD: I think as I hear you talk about this, I think what I would remind people, and I'm curious if you... I think you would agree based on what we started with, is that we influence a lot more of this than we believe that we do.

We think that we're sometimes, that it's out of control, but what impacts our sex hormones is what's going on in the rest of our body. 

[00:27:56] Jennifer Gularson, PA-C: Yeah. 

[00:27:56] Christa Biegler, RD: Our stress and our nutrients and our blood sugar, which you already mentioned those things, and gut function, because that affects how you process all of those things that you're intaking, and your drainage overall, right?

And so the more I sit with people and have seen this, it's like it does go back to, we'll call them basics. They're not necessarily basics. There are things we have the opportunity to learn how to master, and then the downstream effect is that maybe there's a little less erraticism.

We're gonna use this word three or four or five times. Whatever. Maybe there's a little less up and down. We're gonna coin it. Yeah. We're gonna make it up. Maybe there's a little less of this up and down, and that would make sense because every month is a new story, right? The week before that period is a new story because...

And we can prove that pretty easily. People have had these times where... I have a story about a client who said to me one time, "I cannot have another period like that." And we talked about it, and as a high-achieving woman, she said- I don't think I was stressed. Let's review what was going on.

She was a... One or two weeks before her wedding, her fiance had shingles, and she was finishing her master's degree. I think those were just a few of the top things that were going on that particular month, right? Yeah. And so with that stress, it could literally block her COMT, her phase 2 estrogen metabolism.

That's one place we know that stress literally stands in the way and blocks that estrogen from being detoxed, and then that looks like more painful cramps, more breast tenderness, heavier period, et cetera, et cetera, et cetera. And what's funny about that is I remembered that story, and then a couple years later she came back and said, "Hey, I've had some ki- I've had a baby, and I have this going on and this going on."

I said, "Hey, I think I know what's happening. Remember that other time that you had that really tough period, and we learned that you probably struggle with like, this genetic pathway where you cannot even detox this estrogen? When you tell me this story, I hear the same thing happening. So what if we use some symptoms and we just did some good things first instead of, taking a month to test properly," right?

Because people have this- Oh, yeah ... this idea that it's like the answer must be my hormones." And it probably is, but it might not be the hormones you think it is first. Maybe it's your stress hormones first, right? I completely agree. Maybe it's your blood sugar hormones as well. And so I'm gonna die on this hill.

I'm looking forward to it as well. I'm looking forward to it that there's a hierarchy of what's going on in our body, and we know, you brought this up earlier, it's if your body's priority is to make cortisol, whether you think you're making it or not, and running from thing to thing is a pretty good sign.

For me, talking fast 'cause I was excited, I use that example a lot 'cause it's simple, and it was like- ... transformational for me, right? That was stealing from my body's ability to make those sex hormones. So I just share that because as you talk through these things, it's wow, this is fascinating, and holy moly, it's tiring to, to, learn this part of our body.

And that's one, that's a negative perspective of it. But it's hey, and also, when you're doing anything nice for your body, it's going to downstream affect this as well. So just sharing 

[00:31:02] Jennifer Gularson, PA-C: Yeah, I think that so I spend 90 minutes with my patient for the first time I meet them, and the basics of what are you eating, how are you moving, how are you sleeping, what is your stress, what are your relationships?

We spend a lot of time with that because those are the things you actually can control. Sometimes you can't control what's going on in your body. But I think sometimes it's disappointing when I'm like we need to talk about your sleep." "Yeah, but, yeah, but I just want testosterone," or, "We need to talk about what you're eating and your guts and are you pooping, and is your job,

do you really have to do that? And do you really have to have this person in your life? Is this a stressor for you? And, you need to move, you need to... and I can't get you... I cannot get... You cannot do Peloton every single day and crash out every single day." Yeah. "You have to do some restorative.

You have to take a breath before you eat. You need to chew your food completely. You need to, get your salivary glands going." And they just, they're a little bit disappointed 'cause they're like, "It's not that easy." Sometimes it can be- I know ... but all that needs to be really tightened up before we launch into this.

And sometimes it's like I gotta get you on some hormones so that you can sleep, but that then you- Yeah ... can also concentrate and figure out how to do all the rest- Yeah ... of the stuff I'm asking you to do. 

[00:32:17] Christa Biegler, RD: Yeah. And worst case scenario, we learn from everything. I know I was having a chat with someone one day, and she was telling me this story about essentially she had some version of, "I think my hormones are off, so I went to this specialty place.

I flew to this other clinic, this specialty place, and she put me on so many hormones. The simple version was she's "I was not okay. I should have come and asked you." And I said, "Oh, no, you learned so much from that experience." Like- Yeah ... you can't even appreciate a different way until you have a negative experience a different way, right?

It's like you can't appreciate how much power you have and how much you can do until sometimes you have this other experience because we are so attached to what we think our problem is sometimes, right? And what we think the solution is. And that's... I think that's what makes our job a little bit tougher is I can see the physical problems, but I also see how this is gonna continue to be a problem if we don't change, like, how you're dealing with stress.

And I did a lot of additional work after I think not... i'm sure you're like this as well. It's like you just really wanna help people. So you just keep digging for things, and then you realize wow, if we would just do this, and this, a lot of things start to click into place.

But you were doing the amazing work. I'll get back to the estrogen. Okay, so the estrogen, we were talking about it declining in life, but also that there's a peak in perimenopause which makes it interesting, like you said. What's easy is the menopausal woman who's now- Yes ... her sex hormones generally have checked out.

With perimenopause it's like up and down and up and down, depending on what's going on because the body is still moving through some things. It's really transitioning. It's starting to say I don't think I'm gonna need to make this much sex hormone anymore." And with nature we're but I like, I prefer to have these hormones, right?

We like how we feel better with those hormones. So it is a tricky thing, and I feel like we're still in this pioneering stage, right? . You have this incredible seat where you've been here for 18 years, and it's fresh, right? It's still newer. When did we start using HRT?

[00:34:21] Jennifer Gularson, PA-C: Oh, gosh. We've had it in an oral form-... for women. had this for in the '40s and '50s, and then in the '60s and '70s oral estrogen, Prempro, s- and then '80s, '90s, and then all of a sudden 2001, boom, it stopped. I think there was like up to 70% of women were on hormone replacement before this, the Women's Health Initiative, and now we're down to 5%, although apparently it's up to about 10% now, and we can't even keep up with the patches, so don't get me started 

[00:34:51] Christa Biegler, RD: about that.

But you didn't talk about that part where it stopped because they noticed an association. There was some negative associations with the oral estrogen. I don't think you talked about that 

[00:35:01] Jennifer Gularson, PA-C: No. So there is a study, and it's still ongoing, the Women's Health Initiative, biggest women's study that's been...

And we've poured a lot of money in it. And one of the arms, one of the sections of the study was looking at estrogen and hopefully decreasing women's cardiovascular disease risk. So They had different arms of the study, and one of the arms of the study showed a nearly statistically significant difference in women getting breast cancer in one of the arms.

It wasn't statistically significant. And then years later we actually found out that particular arm, the control group, had a lower than normal amount of breast cancer. So it skewed and made the treated group look like it had too much. So that's one little sliver.

But also, we were using medications we don't use anymore. So they were using Prempro, which was synthetic estrogen, synthetic progestin, pregnant horse urine. The s- same things we use to make our birth control pills. We don't use those medications anymore. I think there's even, in my opinion, there's a controversy with the oral estradiol that's available today as opposed to the oral estrogen that's synthetic that we used in those studies, whether or not that blood clot risk actually is there.

So I do have patients on oral estrogen. I prefer not to because the consensus is that it's safer to use transdermal or through your skin, so patches and creams. But for some patients it just might not work. They just might not be able to use it. They are allergic to the creams or allergic to the adhesive, so I will use the oral.

So before this Women's Health Initiative many women were on estrogen. And it's an evolving science. So they at one point they were just on estrogen and they weren't given progestin, and they got an increased risk, about a 4% increased risk of uterine cancer. So then we're like, "Okay, we need to take estrogen with progestin," and that's where we get the Prempro.

And that was just given out like candy in the '60s, '70s, '80s, up until this came out. And if you've ever read Avrum Bluming's book, Estrogen Matters, As a clinician it really made me angry because he describes what happened behind the scenes with that study. Wow. And it was really kinda disgusting.

And, I'm not a conspiracy theorist Although some of my friends probably think I am. But it just, it seemed as though there was a handful of people that really just didn't want estrogen to work. They really wanted... there were books out before age naturally, just, let it decline and everything will be fine.

But we know that there are long-term chronic diseases, diabetes, osteoporosis, dementia, cardiovascular disease. All of those are because of the lack of estrogen and other things. I mean- ... it's not just that. But we have the ability. Now we have a t- 20 years to 30 years of women who haven't had these hormones, my mother included.

Thank goodness she was on it for three to five years. But we have 25 years to look back at these women who were in the studies, and now we know that we did the everybody wrong, and that's it's been reversed. In 2019, a paper came out around November of 2019, and you know it takes time for papers to make it into use- Oh, 100%

make it into use for people to see, but then also into conferences and learning things, and then boom, March of 2020, everything's shut down. It got buried for a little bit, but I feel like in 2021 when people were you know, doing podcasts like yours and out there it resurged and they're like, "Hey, this paper came out.

It said it's not as bad as it is." And then even then it took freakin' six years or seven years for the FDA to say "Oops, we made a mistake. We're gonna take off all these warnings." However, that only came after they took the one off for men for testosterone, which I find is interesting. Oh, we made a mistake with men, so we're gonna take that warning off of testosterone for men, which we've known for years and years all that stuff was crap.

But then we're, now we can take it off for the women. It should've been reversed, but that's my own diatribe. Sorry. 

[00:39:13] Christa Biegler, RD: Yeah, so it was just a couple of years ago that the FDA finally did that? Is that what I was thinking? I was thinking man, the years are blending together if this is 2019, right? And now we're in 2026.

So- But ... 

[00:39:23] Jennifer Gularson, PA-C: yeah, 2019 was when that look back paper was published, but nothing was ever done with it. But now, a couple months ago they take it off of estrogen, and then the men- ... were a little couple months before that. 

[00:39:35] Christa Biegler, RD: Yeah. Okay, you were talking about sourcing of progesterone as well in horse serum.

Where is Prometrium sourced from? This is the most common oral type of progesterone people get prescribed. I thought it was a synthetic. 

[00:39:49] Jennifer Gularson, PA-C: so progesterone- Yeah ... that you can write a prescription for is bioidentical. It's from soy and yams. That's where the bioidenticals are manufactured 

[00:39:59] Christa Biegler, RD: from. But Prometrium is a synthetic, or it's not a bioidentical, is it?

[00:40:03] Jennifer Gularson, PA-C: Prometrium, that would be a brand name. I write for progesterone. So anything with progestin or- ... I-N at the end, or anything that doesn't say progesterone is a synthetic. Okay. Progesterone is manufactured. It doesn't mean that I went out back and I picked up progesterone and put it in a pill.

It's synthesized from soy and yams. 

[00:40:22] Christa Biegler, RD: That was what I usually see people on orally is Prometrium. Yeah. 

[00:40:26] Jennifer Gularson, PA-C: Yes. It comes in 100 and 200 milligrams, so a lot of times... And but it's also immediate release. So for a lot of my patients I use compounded sustained release. Especially if they have anxiety, I like to have that throughout the day, because that's what your body does anyway, it pulses it throughout the day, it just doesn't dump it at night. 

But and it also it's just interesting that the Prometrium, it's in a little gel cap, and it is in a peanut oil.

Oh. So you probably, if you get it, it says if you have a peanut sensitivity you shouldn't take it. I've had a patient do a deep dive into it, and it looks as though in the manufacturing process they take out all the allergens out of that, but why would they pick peanut oil? That's- It 

[00:41:05] Christa Biegler, RD: is an unusual thing, right?

It's because we're women. And that's 

[00:41:08] Jennifer Gularson, PA-C: usually... 

[00:41:08] Christa Biegler, RD: Yeah, it is the case for most oils they don't have allergens. Generally, like it's so refined, but that is bizarre. I didn't know it was in peanut oil. And I have just tiny sliver of experience with this compared to you, but my experience was that sometimes women would come in on Prometrium, they wouldn't really see a difference, and so they would try topical bio-identical progesterone and actually feel better, which kind of corroborates some of what you said where it's immediate release, so that could be the issue, whereas you were doing more sustained release, et cetera.

So I know I jumped over to progesterone a little bit- That's okay ... there. Why do we have patch shortages going 

[00:41:43] Jennifer Gularson, PA-C: on? 

[00:41:45] Christa Biegler, RD: Speaking of conspiracy theories. 

[00:41:47] Jennifer Gularson, PA-C: I know. So you know- I'll try and be nice here. We knew this last year before they came out with the taking out the black box warning off of estrogen we had shortages last summer.

So it's nothing, it's just s- way worse now. But as soon as those labels came off and the hysteria wasn't there, and the stigma wasn't there, I think more and more women were, are asking for this. So like I said before like after the Women's Health Initiative, we were down to 5% of women doing hormone replacement and now it's doubled.

So it's just a supply and demand, and then when you take into consideration that it's a generic product there's not a lot of money in generics. However, when you think about how many women there are, and how many menopausal and perimenopausal women there are in this country it's pretty bad that we can't keep up with the demand.

They should have known that this was gonna happen. It was already happening. The shortages were already there. But I have patients every day calling two and three pharmacies just trying to find a box 

That's tough And it's frustrating. Yeah. And then, it doesn't help that the FDA, Marty McKay, comes on and says, "We do have a shortage.

We know. It's good though because more women are getting hormones," which I agree, but then says, "But you can just take other forms. You can just do... women just settle for just suffer more or just figure it out." I'm like if it were me, I would say, "It sucks. This is what I'm doing to try and fix it.

I'm trying to incentivize them to make more." That was just one of my pet peeves. I'm like, what are you doing to rectify the situation? Are you incentivizing them to make more faster? For a while, it was like, oh, maybe it's because they're changing the insert because they changed the language on it, and they're trying to take that out, and production slowed down.

Maybe that has a little bit to do with it, but I think the big thing is women are demanding it, and practitioners are getting, having to learn because a lot of times your listeners probably know more than their practitioner because we didn't learn any of this in school.

It was- Yeah, that's tough ... it was taboo. We were gonna kill people. So I think more people are getting educated. There's more education online. Their patients are demanding it. They feel like they need to offer it because in my opinion, it's a life-saving, life extender, longevity, quality of life, and disease prevention- 

[00:44:06] Christa Biegler, RD: Yeah

modality. I wanted to highlight the thing that you said that we have talked about here before, but it has been a long time. Maybe when Felice Gersh was here, who knows who it was- I love her ... talked about that. I love her. She's so cute and funny. And she's always doing adorable Instagram Lives and is always talking about the most interesting, I think it's great when people are real clinicians. You can tell, right? You can tell based on their experiences. Anyway, I don't know who first shined a light on this, but I just wanted to highlight something that you just said, which just correct me if I'm wrong, about 20 years after the decline of estrogen, women have an increased likelihood of bone issues, cardiovascular issues, and dementia.

And so that's what you mean by, these- Yes ... in, in case someone missed it, as you were talking about it before, it's oh, wow, interesting, type thing. And so it's really interesting, right? We weren't, I guess we weren't meant to live as long as we are, right?

And so that's part of the evolutionary challenges we face. And so one of the conversations that comes up a lot with hormone replacement therapy is, okay, but once I go on, I'm not getting off. So talk about that. 

[00:45:10] Jennifer Gularson, PA-C: Yeah. We used to say you'll be on it for 10 years and then you'll stop. Then your protection is gone again.

So there's a reason, in perimenopause- I have a lot of patients come in, be like, "I've changed nothing, but my cholesterol keeps increasing." I'm like, "Yes, because your hormones decrease." Estrogen and testosterone and progesterone are decreasing, so your body is signaling, "Hey, we need some hormones," and guess what the building block of all hormones are?

Cholesterol. It's cholesterol. So that's why, sometimes decreasing your statins too can cause some problems.

[00:45:41] Christa Biegler, RD: I'm so glad you brought that up. I was talking to another clinician friend about

and I wouldn't have even remembered to ask you about this. Basically, I asked you about once you go on, you never go 

[00:45:52] Jennifer Gularson, PA-C: off. Oh, once you stop, yes. So in my history of practicing, it was, yeah, you'll go on for five to 10 years because it is dangerous and there is that risk of breast cancer, but your symptoms are super bad and the benefits outweigh the risks right now for you.

And then it was, "Oh, we'll do it for 10 years." Now it is my... I tell patients, "You're on this for life," because we know that it's protective. We now n- have so many more studies. We have studies looking back at the Women's Health Initiative, even though it was stopped early because of the breast cancer scare, we still have data from patients that were on it from three to five years, and even those women have less dementia, less cardiovascular disease, and less overall cancer, less overall death, even for that small five-year period that they were on.

So then what are we gonna see with women who go on it, and stay on it forever? So we used to say 10 years, now we say forever or unless there are risks that change for you that make it that you shouldn't be on it. So those are the current recommendations. You're on it for life.

[00:46:59] Christa Biegler, RD: I wonder if dosages in menopause, if someone's been on it for a long time, need to change for any reason because as you can imagine, as you very much are very aware of, it's hard to find a good clinician you would trust to put you on hormones. And so I'm curious about how often you are changing dosages after someone is in a really...

Let's say you're well beyond perimenopause and you're into menopause, so it like, in our thought, it's status quo, but how often are things changing after a certain point? 

[00:47:31] Jennifer Gularson, PA-C: So I don't know. I just started really treating perimenopause say five to six years ago. I was only seeing patients who were seeking help who were in menopause.

And now actually the rule of thumb, and this is a nice statistic, is we want you to start before your age is 60. So before the age of 60, and within 10 years of you being in menopause. So that is saying let's start earlier because after that age... But that's not to say that if I have a 70-year-old that walks in today, I might, I probably am gonna put them on something if that's what they're seeking, and they're...

We go through just more more information. We, I get more information and more history and more labs on those patients. But at the time, so when we're younger, higher dosage. If I have a 70-year-old who hasn't been on anything and wants to start, then I usually start really, at the lowest patch and the lowest progesterone because over time, yeah, those receptors downregulate.

I'm not sure if we know if you start in perimenopause and go through menopause and stay at that same dose, is that, do you still have receptors that haven't been seen in years? They're continuing to see the estrogen, but do they downregulate? I can't speak to that.

I just know that that we're keeping women on it. And the barrier though is the endometrial bleeding. So sometimes I'll to get the estrogen up to the dose that I want, I'm fighting their endometrium building up and giving them the enough progesterone so that they don't bleed.

So that I think is something that is frustrating. And, as soon as you have post-menopausal bleeding, you should see your GYN, you should get an ultrasound, and your endometrial stripe is looking... you're gonna look at that stripe. But do we need to change the numbers for how thick your endometrial stripe is for patients who are post-menopausal but on hormone replacement?

Is that changing? Because, if you have a little bit of bleeding, you go in for that endometrial biopsy, it's not pleasant. And then what are the standards? If you have a little bleeding one month but then you double up your progesterone. So it becomes very complicated. But the goal is to give them the least amount over the longest amount of time so that their symptoms are not there, but are relieved, but then you're also giving them that longevity and not putting them on any jeopardy.

[00:49:53] Christa Biegler, RD: Yeah. Cool. There's so much we could talk about, but I think the question that will allow you to summarize whatever you wanna say about this is really if you could give yourself advice five or 10 years ago, or now looking back at this experience that you have, what advice would you give yourself to age well related to hormones?

What advice would you give yourself now for setting yourself up for the best possible outcomes? Because, one of my thoughts about this is trying to take care of my body as it is now to delay the need for hormone replacement therapy until I really need it, right? To be not 35 or to be...

And everyone's got different scenarios, right? So to be as old as possible before- ... I would need to use hormone replacement therapy by taking care of all of these systems and these foundational systems. And so I'm curious what your opinion is, having such a big seat, front row seat to this for s- for quite a while, and getting to see quite the changes, so I'm really curious what your advice to yourself would be.

[00:51:02] Jennifer Gularson, PA-C: I think I was... lucky 'cause I was in a position to treat myself and say "Huh, I wonder what it's gonna be like if I do this. What if I do that?" I would've liked to earlier in my 30s, like sorta reined in the exercise. I was a college athlete, so I always did something.

But I think doing the longer workouts, all the cardio, all that stuff I wish I would've maybe lifted a little bit more earl- in my 30s and 40s. I'm doing that now, but thank goodness I did it way back in my 20s. Taking time for myself, like not feeling selfish, feeling like I have to please everybody else.

So that goes to taking time for yourself and decreasing stress, all that stuff. Prioritizing sleep. I wish I'd stopped eating gluten earlier than I did. It took me a while to figure out, it was, like, in my 40s, I think, then finally I was like, "This doesn't feel good for me." And yeah, I started progesterone when I was about 35.

I started testosterone at about 37 and did really well throughout until I added my estrogen. So I think w- advocating for yourself, finding the right clinician, knowing your body, knowing that at some point you're gonna possibly need this. But yeah, reigning in all that other stuff and, getting back, we started talking about libido- This whole conversation about libido.

I think for women, really giving them permission to step into their femininity, to feel confident, to ask for what they want, and to know how their body works so that they can share that with their partner. And as we age, I wish my 30-year-old self was take- or fort- let's say 40-year-old self was starting on vaginal estrogen way back then so that

you don't get any atrophy, that you keep that tissue down there expanding to keep your blood flow supply there so that your orgasms are still there. I think that's really important, too. And using lubrication, 'cause I always thought if I use lube, that means that I'm not excited and I'm not excited for my partner.

Not true. So all of those things are to say I'm doing things now at 50. I'm 53. I'm doing things now at 50 so that my 80-year-old self will be still have a libido and still have fun and have sex and not be risking getting pregnant. That's the whole part, right? 

[00:53:25] Christa Biegler, RD: Yeah.

Funny. I think it's great to just ask ask someone this. Now, about stepping into femininity, I just wanted to say that going back to the beginning of the conversation with high performing women and just how we are in the workplace, we are operating in our masculine so much, which means we're- Yes

pouring out into other people all the time. And I think for most of my life, I thought that was feminine, was to pour into other people, and to be in... The feminine is to be receiving. Yes. And that is very hard for a lot of women, right? Especially as we've, really shifted to being both powerful people.

And I think when there's not this balance of that in the relationship. And men can be in their feminine as well, right? We can have an exchange of this, but that was so enlightening to realize that, oh, being a woman, To lean into the feminine is to receive. And so having that imbalance where two people are trying to be masculine in a relationship will absolutely tank, Yes

libido for sure as well. So- Yes ... a little side note related to what you were talking about. But to that end there's more to it, right? It's the physical things that we really deep dove on a little bit today. And it's those other basics that are essential, and then it's beyond that as well, like how we're feeling, in our head for other reasons also.

So Jennifer, thank you so much for coming on today. We could have easily talked for two hours about this- Oh, yeah ... and it was great, and it was wonderful, and I'm sure you'll be hearing from people. Where can people find you online? 

[00:54:49] Jennifer Gularson, PA-C: So my website is yourbestlifewithjennifer.com. And my brick-and-mortar, I'm here in Rockville, Maryland.

I see people in Maryland, Virginia, DC, Delaware, West Virginia. And then also I'm on Instagram. It's just my name, Jennifer Golerson. 

[00:55:04] Christa Biegler, RD: Awesome. Thank you so much for coming on today. 

[00:55:07] Jennifer Gularson, PA-C: Thanks!