In anticipation of this month’s Functional Forum, we bring you this very special Podcast: The Evolution of Endocrinology, featuring functional endocrinology expert Dr. Mark Menolascino of The Meno Clinic in Jackson Hole, WY.
This podcast was recorded several years ago for the first Evolution of Medicine Summit, and provides a wealth of clinical pearls and practical tips on today’s endocrine-driven chronic diseases.
Tune in now and get up-to-speed on the latest in functional endocrinology, including:
- The difference between conventional medical endocrinology and functional endocrinology
- The surprising laundry list of chronic conditions rooted in sub-optimal endocrine function including adrenal fatigue, erectile dysfunction, thyroid ailments, diabetes and more…
- What Dr. Menolascino believes are the top 2 misunderstood and mismanaged endocrine conditions
- The role of the gut-liver connection in hormonal function and balance
- The real story behind the endocrine-cancer-connection
- How and where to begin unraveling complex hormonal issues
- …and much more
And if you’re hungry for more information and best practices in functional endocrinology, click here to join us for this month’s Functional Forum: Evolution of Endocrinology LIVE from Minneapolis, MN.
Will you be in the Minneapolis area Monday, September 10? Click here to get 2 free tickets to the LIVE show using the coupon code “Dutch”, courtesy of our sponsor: Precision Analytical.
Resources mentioned in this podcast:
Functional Forum: Evolution of Endocrinology
Announcer: Welcome to the Evolution of Medicine podcast. The place health professionals come to hear from innovators and agitators leading the charge. We cover the latest clinical breakthroughs in health technology, as well as practical tools to help transform your practice and the health of your community. Now, here’s your host, James Maskell.
James Maskell: Hello and welcome back to the Evolution of Medicine Summit. This is James Maskell here and I’ve got a very special guest all the way from Jackson Hole, Wyoming. Dr. Mark Menalascino on the line. How are you doing, doc.
Dr. Mark Menolascino: I’m very well. Thank you, James.
James Maskell: Great to have you here on the line. Dr Menalascino and I have known each other for a few years. We met at the Heal Thy Practice Conference in 2011 and I’ve had an opportunity to go out and see the work that he’s doing in Jackson Hole and I just had to have him on this summit because we’ve been in conversation for the last few years about topics related to the evolution of medicine. I really wanted an opportunity to share with the world some of what Mark shared with me because it’s been very formative in my understanding of things.
So Mark, one classic theme that’s gone through all of these talks has been, everyone really has a really good reason why they’re doing what they’re doing. And I know that your reason for getting into medicine goes back at least a generation. So do you want to just start by sharing everyone sort of why you’re doing this and your journey to getting here?
Dr. Mark Menolascino: Well, my pleasure, James. And you’re absolutely right. As you go to the conferences and you talk to your peers, everyone came to this type of medicine either as a transition from what they were doing in traditional medicine or they started this from day one, which I was fortunate to do. My father was a psychiatrist that really believed in the way we treated the developmentally disabled was inappropriate in this country, and he led the charge to develop all of the social service programs we use the developmentally disabled. And I’m the fourth doctor in my family. One of my brothers was a chiropractor, then became an internist. He worked at the VA. My sister went to China for two years. Now she’s a psychiatrist in Manhattan. My other brother’s a mainstream internist, works downstairs, we’re best friends, we share ideas.
But when I was a senior in high school, Dean Ornish showed up in Omaha and said, I’m going to take 100 men who’ve had heart attacks that are scheduled for bypass surgery and I’m going to talk them out of it, put them in a lifestyle nutrition meditation exercise program and I bet they do better. That was a game changer for me. I was a research technician with him. He’s now one of my mentors and a good friend. It showed me at the very beginning that you have to do good medicine, which is why I think internal medicine was good training to be a good diagnostician, but along the way develop this training and skills for homeopathy, naturopathics, Ayurvedic, Chinese medicine, acupuncture.
I think it’s a toolbox. So when someone comes to see you, it’s not a one size fits all or a pill for the ill or a potion and a lotion. It’s you have a toolbox of tools and you have a repertoire to discuss alternative therapies that they’re doing with other practitioners in a way that doesn’t alienate you from either your patient or from the practitioner. I think this whole idea of functional medicine is really where this is headed towards.
James Maskell: Yeah, that’s so awesome and exciting. I know you’re also the chief medical officer of neuroscience and I know you have some background in immunology and so forth. So, you know, it might be surprising to the people who are today that we’re going to talk about the evolution of endocrinology. Talk, in your opinion, why is it appropriate for someone with a background in internal medicine, immunology, and neuroscience to be talking about the evolution of endocrinology?
Dr. Mark Menolascino: Well, I think when you think of endocrinology, you think of conventional medical endocrinology, and when we think of functional endocrinology, it’s really something totally different. There are some commonalities, but it ends up being somewhat mutually exclusive. In Medicine, we were taught the Rene Descartes reductionist models, to break everyone down to the smallest parts so we know what single piece to fix and what pill to give them. The other thing that we’ve done really as a disservice to our patients is that these normal ranges are really a population bell shaped curve that we regress an individual to the mean of a population. Most people don’t want to be average in America because average in America is what James? It’s diabetic and obese.
James Maskell: Yeah, it’s very sick, especially in the middle states where you find yourself.
Dr. Mark Menolascino: You look at the maps of the states, 15 years ago, only one state had a population over 30 percent obesity. Now no states have a population under 30 percent obese. The numbers, one in three children born today will be diabetic, and then these numbers are just scary numbers. And I really think the functional medicine model is going to be the one that fixes it. When I sit down with a client, particularly with my female clients, because they are more complicated, their hormone symphony is more of a delicate dance, we talk about the symphony. And it’s a hormone symphony of the pituitary gland as a conductor. She talks to the thyroid, the adrenal gonadal, which is the ovaries or testicles mediated through the gut. If you get those members of the symphony in harmony and help the conductor to behave, good things happen and people enjoy optimal vitality.
And so, if you’re going to the old fashioned way of just someone fits the normal range, you check the box and kick them out of their office even though they’re tired, they’re depressed, their mood’s low, they’re cold all the time, they can’t lose weight, they’re constipated, their gut doesn’t work, but their tests are normal. That’s why a lot of our clients are frustrated with the conventional medical model because it doesn’t help most people that have a multitude of symptoms.
What’s also interesting is the thyroid ranges, most thyroid labs are still using the old fashioned range that the clinical endocrinologists have lowered. So there’s literally millions of Americans out there with subclinical hypothyroidism that should be treated either functionally, nutritionally or medically to support their optimal health for thyroid. So, that’s one of the biggest things I see as inappropriately or inadequately managed thyroid medicine.
James Maskell: So these numbers that are being going against, is this just like a new normal? Why are these numbers changing? I see that in quite a lot of, we’ve had a lot of talks actually, there are talks about new normals and medicine, which seems a bit of it scary. What’s going on here?
Dr. Mark Menolascino: Well, I think again, what we’re shooting for is what we just talked about, normal. Normal is probably not good enough and if you look at our healthcare system, it’s obvious we spend the most and we’re like 32nd on the list of quality of care. There’s just been a bigger movement to really look at people more individually and more optimally. The TSH range used to be 5.0. If your TSH is high, your thyroid’s low. There’s two separate endocrinology groups. One is at 3.0, one is at 2.5. Now, these aren’t the Jackson Hole group of alternative medicine functional doctors that think that these are the new normal. These are the clinical endocrinology specialties.
And so again, I think you’re seeing more tighter ranges for some of these normals. And a lot of what you see in lab normals are just not optimal numbers for what clients are looking for for optimal health.
James Maskell: Yeah. So if we take a step back, the endocrine system is really, it seems to me they really can’t be seen in isolation just because really the major role of this endocrine system is communication throughout the body and it’s communicating with almost every other part of the body. Do you want to just, for those people on the line that I know we have endocrinologists probably listening. We probably have medical stakeholders, we probably have patients and so forth. Do you want to just give us sort of a quick outline of just all the different aspects that endocrinology and the endocrine system interacts with?
Dr. Mark Menolascino: I’d be happy to. In one summer, I did a presentation at the Society for Neuroscience as well as the same week at the Society for Psychoneuroimmunology. And this was early in my career, and I saw that there was such relationship between doing good neuroscience, but also the relationship of the mind, body, spirit was actually technically viable. That there is a discipline of psychoneuroimmunology, that the mind and body work together. Your nervous system is really the matrix of structure. The immune system is your communication system. Your nervous cells, the cells in the brain and the cells in the body, they have receptors and cytokine receptors for the immune chemicals, and your immune cells have receptors for your neurochemicals. There’s a cross relationship at the cellular and biochemical level between both the nervous system and the immune system.
I did a masters in pharmacology and immunology, ran depression clinical trial center and I really saw how, if you’re depressed, are you really more likely to get sick, more likely to get cancer? Well, we’ve proved that. A good example is with heart disease. Once you’ve had your first heart attack, what’s your biggest risk for having a second heart attack? It’s not cholesterol like we were taught and it’s not inflammation like we know most heart diseases. It’s depression. When you’re depressed, you have a low heart rate variability, which is a sympathetic parasympathetic abnormality that doesn’t have the dynamic response for the parasympathetic and sympathetic nervous system, which then has a whole host of downstream immunological complications and communications.
I really think that that’s a great example of where the functional system of neurology and immunology and pharmacology come together. When you treat those patients with low heart rate variability that are depressed, their heart rate variability gets improved, as well as their depression/dysthymia.
James Maskell: Once you realized this was going on, Mark, what steps did you take to really get a handle on how all these things move together? Because there’s very few education organizations that are teaching how to bring all this kind of stuff together at this stage. I mean, I hope after this summit and moving forward there’ll be a lot more and it’ll happen all over the world. But I think America is really being leading the way with functional medicine, but I know there are other organizations that you’ve turned to for education in this.
Dr. Mark Menolascino: There really are. I’ve been fortunate in my career, I was lucky enough to have several mentors. Dean Ornish, George Solomon, who was the father of psychoneuroimmunology. Working with Andrew Weil’s group. There’s a lot of good people out there, and if you’re just starting in this, and I would encourage you to find a mentor, by going to the functional medicine conferences, I’ve had several people ask me to help mentor them and I’m personally guiding probably a dozen positions, helping them figure out what tests to order or how to help interpret the test that they do and to help them guIde their therapy plans as well as their educational plans.
I think the Institute of Functional Medicine has done a fantastic job in their modules as well as their annual conference. It’s really hard though for a lot of doctors to be doing primary care Monday through Friday, come to a weekend conference and change the practice they do on Monday. I think the Heal Thy Practice Conference that they have to the holistic primary care group really helps bridge that somewhat by giving you the tools to change your practice. It’s very difficult in America to be a traditional insurance medicare provider and then on Monday become a functional medicine doctor. But there are certain easy steps that you can take, and I do encourage everyone to look at the Institute of Functional Medicine, to look at the A4M, to look at the American Board of Integrative Holistic Medicine, to look at ACAM, look at AEM. There’s great organizations out there that are doing good medical teaching.
I’ve been to 11 conferences in 12 months, partly because this is my tribe. The integrative healthcare symposium in New York city is always a good one. There’s a new one on the brain this May in Florida. So there’s really good education out there. It takes time. The good conferences are expensive as all CME, but I think the thing, my message would be, if you are in your training, do some rotations with doctors that do think out of the box and are trained like this. You can go onto these organizations’ websites and actually, patients can find practitioners in their zip code and in their state, that’s how we’re getting the patients and the practitioners connected, but there needs to be a better model of bringing patients and practitioners together, and I think that’s something that I hear when you speak James about the new model of you seen connecting patients and certified practitioners, that we need to have good people doing good work and allowing easier access for patients to achieve that.
James Maskell: Yeah. Well, we’re sort of, we’re getting that. Thanks for sharing that because I know there are a lot of doctors on who are probably interested in what they’re hearing, but they just don’t know where to go with this next. So, can you give us maybe a few examples, Mark, of conditions or disease types and states that aren’t traditionally in the realm of an endocrinologist but have endocrinology as a sort of a core of the pathophysiology or its function?
Dr. Mark Menolascino: Well, probably the easiest example, James, is this concept of adrenal fatigue. When I talk to the other three doctors in my family about adrenal fatigue, they think of Addison’s disease, which is an autoimmune attack of the gland of the adrenal causing total failure. And that’s not what we’re talking about. This is more of the sick and tired of being sick and tired and the fight or flight response. And again, these people have a story. I spoke to someone last week that their mother in law passed away, their father died a week later. They moved two months later, they became divorced three months later, they lost her job two months later. And they wonder why they have no energy. But all of their tests are normal. When they do a random spot cortisol, it’s normal. They do their hormones, it’s normal. They do the thyroid, it’s in that so called normal range, but these people are tired.
The concept of adrenal fatigue really is more of a subtle imbalance of that hormone symphony of the adrenal than it is an absolute failure. I think that’s the difference between functional endocrinology and conventional endocrinology. In regular endocrinology, we’re looking for something to be absolutely broken before we fix it. For example, blood sugar. The day your blood sugar is 126, you’re not diabetic, the day it’s 127, you are diabetic. Well, when your blood sugar goes over 95, someone should be doing something to help you adjust your blood sugar. So it’s really looking at these optimal ranges and starting over.
There’s also an intimate dance between the thyroid and the adrenal that I don’t think we really understand. The Institute of Functional Medicine put a conference on three or four years ago called The [Sensinal Organ 00:15:46] Adrenal and Thyroid, the Interrelationship. And there’s really a relationship of thyroid. For example, this Addison’s disease, if you don’t recognize true adrenal failure and you give them thyroid medicine, you’ll bottom out their blood pressure and potentially kill them. So there’s a real relationship between thyroid and adrenal. And then the female hormones turn on the thyroid receptor, progesterone particularly, and it’s that beautiful dance. You’ve got to put the whole system into harmony and it’s not just about one thing.
But I think the adrenal fatigue model is maybe one of the most misunderstood. And then the sub clinical hypothyroid, which I mean, their TSH isn’t above five, but they have all the thyroid symptoms. A lot of times those people deserve support either through the gut and there’s fascinating data. One of my favorite books is Why Do I Have Thyroid Symptoms When My Tests Are Still Normal. [inaudible 00:16:43] wrote the introduction, he’s one of the world’s gluten experts. And for a lot of people, they have an autoimmune disease of the thyroid driven by leaky gut and gut dysfunction, which should tie well to your previous lecture about the GI health by your expert, that it’s all interrelated.
James Maskell: Maybe you could just talk people through for people who see like, well, the gut’s down here and the thyroid’s up here. How does that happen? Like how is that pathway actually working?
Dr. Mark Menolascino: Well, there’s a couple of really interesting facts. Number one, there’s 10 times more bacterial cells in your gut than there are human cells in your body. So it’s a pretty important place. Also with people with mood disorders, your serotonin, there’s a million times more serotonin in your gut than there is in your brain. And really the gut, we’ll always call it the second brain, it might actually be the first brain. But there is such a complex neurochemical, biochemical interaction there. Most hormones go through what they call enterohepatic recirculation, where the liver processes it, brings it back to the gut, brings it back to the liver before it becomes an activated molecule. Whether you’re taking it bioidentical or by oral.
And for a lot of us, because of the food we’re eating, the way gluten has changed, with Bill Davis’ Wheat Belly book, with Dave Perlmutter’s Grain Brain book, you’ll see how that’s one food group that has markedly changed that interrelationship of the microbiome of the gut. The gut microbiome is the future of where a lot of the research is going to come that’s going to help us understand this relationship of how what we eat affects how we feel. The leaky gut concept is funny because Andrew Weil spoke at the Natural Supplements Course in La Jolla given by Mimi Guarneri, which is one of my favorite courses because every year they review the latest and greatest data on supplements. He talked about how the microbiome and how it interacted with this term leaky gut, which we had to kind of walk around whispering, leaky gut, in our clinics because our colleagues didn’t understand it.
Now it’s called intestinal permeability and there’s articles in JAMA, New England Journal of Medicine, British Medical Journal, Lancet, on this intestinal permeability. And Anthony Fasano wrote a fantastic article in Scientific American two or three years ago. There’s just some really great data about the permeability of the gut causes a reaction of the immune system that can sabotage the processing of all of your nutrients, the development of the recirculation of your hormones and the optimization of the function of thyroid, adrenal and hormones.
James Maskell: It’s definitely all connected. The germs, I mean, that’s going to be actually a consistent topic throughout the whole summit here is talking about this microbiome because it’s really changed everything, everyone’s understanding of everything from gut obviously, but epigenetics and so forth. It’s really effecting all of those areas and I think that’s something that is part of our understanding of the evolution of medicine because our interaction with microbes is definitely a sort of an understanding of our evolutionary progress.
This is very personal to me, Mark, because my mother is a breast cancer survivor. But I know that there’s a huge connection between the endocrine system and cancer. I know you did a cancer summit summer in Jackson Hole and had people like Kris Carr and so forth out there. What is that relationship between the endocrine system and particularly breast cancer but all cancers?
Dr. Mark Menolascino: Well, part of it is why we’re also fascinated by organic food and by free range beef and free range chicken. If you go to the store and you look at a regular chicken breast versus an organic non hormone fed chicken breast, they’re dramatically different in size. When young girls develop breast buds earlier going into menarche earlier, we’re having higher rates of breast cancer. And really our detection strategies aren’t making that much of a difference. There’s so many hormone disruptors in our food supply and in our chemicals that we use daily. I heard a fact from Kris Carr that the average woman walks out of her house in the morning with 105 chemicals on our body. And the best way for a woman to detoxify herself is to have a baby because she transfers all those toxins to the child.
They did a study of 10 Americans randomly selected from different parts of the country, different socioeconomic factors and found over 300 toxins in them. And these were newborn babies. So again, there’s so many chemicals, so many hormone disruptors in our food supply that what happens is the estrogen that our body makes or that our body sees, it has to be processed through this enterohepatic circulation, which is the gut, enterohepatic liver. And if the integrity and microbiome of that area is not ideal, you develop different estrogen detoxification pathways that can steer you more towards estrogen metabolites that are more carcinogenic than estrogen metabolites that are actually cancer preventative.
There are ways to test for that. That’s why we talk about broccoli and cauliflower and the cruciferous vegetables. Why soy in some forms, particularly the modified soy has some problems with it. It’s really the food supply and the chemicals that we’re being exposed to that are causing this hormone disruption, not just for cancer increased risk, but also for hormone disruption of the thyroid, of the adrenal mediated through the gut.
James Maskell: So essentially, is that the body is producing then too much estrogen as a result of all these foods and plastics and pesticides and toxins and so forth and there’s just too much estrogen floating around and not getting broken down by the liver?
Dr. Mark Menolascino: Well, it’s two things, James. One is what did I say the average American is, obese. And what does body fat do? It’s an estrogen factory. So again, you’re making extra estrogen if you’ve got extra body fat on. Then if you’ve got a dysfunctional gut and liver relationship, you’ll take that estrogen as your body breaks it down and you’ll make more carcinogenic forms and metabolites of estrogen. You combine that with the food supply and a chemical supply that’s full of hormone disruptors, particularly estrogen modifiers and it markedly increases not only our exposure of estrogen to the cells but also the types of estrogen that are cell C and the circulation of it for the excretion of our bad hormones.
James Maskell: Okay. So, you said the best way to detox is to have a baby. I know that’s sort of tongue in cheek and sort of a horrible, horrible thought.
Dr. Mark Menolascino: It’s a very scary thought, and I hope that doesn’t offend people, but this is actually a well known fact that the mom transfers a lot of toxins to the baby during pregnancy and then during breastfeeding. I still encourage breastfeeding because of the immune protection. But it’s more of a sign of our relationship to our environment right now. The number of chemicals we’re adding every year to our environment is amazing. The skincare products is a separate topic and Kris Carr talks a lot about that. There’s so many toxic things in our skincare products. I took my 12 year old daughter skincare products and turned them all over and there are many carcinogens in those products. And so, we’ve been really hard pressed to look at the dirty dozen, the clean 11 and really trying to make good decisions on not just the food we eat but the products that we use on our skin and our body and in our homes, in shampoos and soaps and skincare and lotions and in facial care as well.
James Maskell: Yeah. Well that’s a big part. I completely agree with you. I read this amazing book actually when my wife was pregnant called to Having Faith which was by Sandra Steingraber, who is sort of like an ecologist view of motherhood, and she was talking about sort of like the ecology of the womb essentially and how the womb is an ecology of sort of n equals one, but there are all of these factors that are coming in there. It was one of those kinds of books which is very captivating and very interesting, but a sort of one of those books that you can’t read more than a chapter at a time because you just want to lash out at someone for what we’re doing to these next generations.
Looking forward, Mark and looking at the evolution of medicine, it obviously makes sense to me from what you’re saying is that we need to first of all, not purchase so many chemicals. I mean, there’s certainly toxins that you come across that you can’t really do anything about. Those that you breathe in or otherwise, but you know, not purchasing chemicals that you’re going to put on yourself is probably a good next step. When people talk about detoxification and I know that’s a a big word that has a lot of different meanings to different people, what are the sort of foundations that you’re laying when you work with patients to make sure that detoxification can happen in a sort of a safe and structured way so that you’re not doing more damage in the longterm?
When someone comes in and they’ve got obvious endocrine disruption, obvious estrogen, you know, sort of hormone imbalance and obvious toxicity, what’s the sort of a game plan that you lay out for patients to get to a more optimal place. I love the idea of the symphony of hormones and the dance that you mentioned at the beginning. Where do you start when you deal with your average patient that’s a mess?
Dr. Mark Menolascino: Well, you know, James, we’re talking about endocrinology but for me it’s all about the gut. I grew up with irritable bowel. I had every test known to man. My dad was the chairman of medicine and they couldn’t figure it out. And now irritable bowel in my practice doesn’t exist. Fibromyalgia doesn’t exist. Chronic fatigue doesn’t exist. If you listen to Jacob Teitelbaum, he’ll tell you everybody diagnosed with chronic fatigue or fibromyalgia is probably subclinical hypothyroid. This is the world’s expert on those two topics. And again, it doesn’t mean that you give everybody medicine on the front end but you’ve got to be thinking about that.
I think detoxification is a loaded term in America and a lot of people go through cleanses and detoxes and it actually makes them worse because they’re releasing the toxins from their tissues before their body’s ready to actually handle it. So I think, there’s medical terms we talk as physicians, but I like to make things simple. It makes it easy for me, easy for my clients.
You’ve got to get the gut healthy, then you’ve got to spin the liver better. So you’ve got to get the gut healthy by finding food sensitivities, removing the foods that are causing leaky gut, heal the leaky gut barrier with glutamine and probiotics and then getting the liver with milk thistle, inositol 16, maybe glutathione. But get the gut healthy, support the liver so it can adequately do its job. Otherwise you’re just taking these toxins, running them through the liver, it can’t handle it. It gives them to the gut in a more inflammatory way and gets put right back to where it was and you’re worse than when you started.
James Maskell: Seems like supporting the liver as well and doing that work is going to help with the hormone balancing too because the liver plays a huge role in that.
Dr. Mark Menolascino: It is. And again, your liver is your detoxifier and the phase one, phase two. And you know, we’ve lost a lot of medicine by going so microscopic molecular reductionist that really the physical exam has been lost in a lot of people. You look at the nails, you look at the tongue, you look at the skin. You can see a lot of the things going on in the gut based on the physical findings. A low core temperature, scallop tongue, full thyroid, delayed relaxation of reflexes. Those are all classic thyroid signs no matter what your blood test says. So your blood tests may be in the even the new normal range, but this thyroid at the cellular level isn’t able to respond because there’s something that’s blocking it.
Another good example we see is with women that are unable to conceive because their progesterone is in the so called normal range in the luteal phase, they’re not treated. Well, we’re a little more aggressive and we get them in the high end of that optimal range, not the low end. And lo and behold, they become pregnant. We have about a dozen hearts on our table here from women who did everything and could not conceive. We pushed the progesterone levels still normal range but to the very upper end of the limit and they’re able to conceive and carry it to term very well. We’ve got three more women this month that are actually in their 25th, 26th week that are also delivering. That’s another great model of how conventional endocrinology failed because their progesterone was in the normal level.
Another great pearl for the docs out there and clients is I like the Grand Canyon analogy. If you look at the normal range for thyroid, my lab is .5 to 5.0. It’s like the Grand Canyon. Now if you’re standing on the south rim of the Grand Canyon or the north rim of the Grand Canyon, you’re technically still in the Grand Canyon, but isn’t your view a little bit different? So where’s your view the best? Where on that spectrum, where on that bell shaped curve of a population average is your view the best? For some people it is the middle. For some people with anxiety it’s a little lower. For most people it’s in the top 10 to 15 percent. And it’s the same for testosterone therapy, the same for progesterone therapy.
I’m using less estrogen over time because of all the estrogen in our environment. I like Indole-3-carbinol, DIM to try to help detoxify for estrogen. We’re testing levels. I can’t tell you how many people come in here on hormone therapy and don’t get tested. It’s the same as if you were to have thyroid medicine and never get your thyroid checked. I just don’t really understand that. So, I don’t believe in excessive testing but I believe in optimal monitoring and there’s set algorithms from things like the Institute of Functional Medicine, the A4M that have these tried and true safe algorithms so you can be on these type of therapies and have them monitored appropriately.
James Maskell: You mentioned one thing which I think has been another, another big theme of this summit is individualized medicine. Do you want to just go into that a little bit about how that fits particularly with endocrinology? I just feel like the normal range, when you say normal range, what that sort of says to me is that, in the past medicine or in sort of reductionist driven medicine, what we’re really looking for for most people and when we look for drugs or we look for other things is what one intervention can we do on all of these people that’s going to get the most people to a better health state. I think that part of this evolution of medicine that we’re seeing is like, you know, everyone’s different and we need to treat everyone differently.
There’s obviously like, there’s obviously principles and physiology and so forth and I think one of the key things about functional medicine is this understanding of systems biology. But coming back, and everything interacting with each other. But let’s look at individualized medicine, why you feel like that is so important because it just feels like that’s another trend that we’re seeing in this evolution of medicine is a shift away from trying to find the thing that’s best for the biggest part of the population because no one really represents the average. And just looking at individualized medicine, what’s your take on that, Mark?
Dr. Mark Menolascino: Well, I think these are really pertinent points with what’s happening in the healthcare system. And really we’re talking about two types of things. Allopathic is a medicine that you’re used to getting from your regular doctor. When you have acute illness, allopathic medicine is really quite good for that. If you have a severe life threatening pneumonia, then you need antibiotics. The way I think about antibiotics, the antibiotic doesn’t kill the bug. Your immune system does it. The antibiotic just lowers the threshold enough for your immune system to do its job. And so, thinking about people that way, but when you’re critically ill, acute care medicine works very well.
The problem with America is that we’re full of chronic illness. The acute care model fails people with chronic illness. I can’t tell you how many people come in here and I ask them about their energy level and they’ll say, yeah, I live at about a four or five, and they’re okay with that. And it shocks me because they felt that way for a long time, and I’ll hear a lot of people say, well, you know, I’m 55, I’m just getting older and I guess that’s just what happens. I live in Jackson Hole. We have at least 11 Olympians here. We have people who are 70 years old who can outski me and can outrun me. So, I know firsthand that age is not a barrier. I like to tell people you’re not your chronological age. The piece of paper may say 65 but why can’t we have you physiologically at 55?
And myself personally, I don’t want to live to 120, but I want to ski with my kids when I’m 80. It’s about your functional status. We’re taught in medicine that you hit your peak at 50 and it’s a slow decline to the nursing home. Well, I like the square curve theory. Let’s get to your best this year and let’s work together hand in hand to keep you on that flat curve until your very last day. And so, I think we’re taught that we’re not supposed to have optimal vitality as we age. We’re supposed to age and get tired and let this go down. But what’s beautiful in America right now is that we have a very educated population that gets this and they’re challenging their doctors, they’re looking for people like us that help them to achieve that vitality. And once they achieve it, their spouse sees it.
I can’t tell you how many times a husband or wife comes in, we get them dialed in and their wife shows up a month later because they want some too. Or their brother does or their neighbor does or their best friend does. It’s spreading like wildfire. You don’t really have to advertise this kind of medicine because your clients are your walking advertisement. They feel better, they look better, and they share that with their friends because everybody wants that now. There’s a unique way to deliver it and there’s ways to learn how to do it and the shift is the way to do it.
James Maskell: That’s such a good point. And yeah, we do see that. Women typically take care of themselves better, are more concerned about these kinds of things, seek help earlier. Yeah, they can become a billboard to others and then you suddenly get the men coming in.
Let’s talk a little bit about men’s health because I know it’s slightly different. I know one of the big things obviously that when you think about men’s endocrine health, the number one thing you probably think of is Viagra commercials. I heard someone say a few years ago that this massive increase in the erectile dysfunction was basically just the sort of the end of a cycle that started with all of the cholesterol lowering medication. Do you think that’s true? And if so, could you sort of explain how that would work?
Dr. Mark Menolascino: Again, I’m a simple guy. I like to use visual aids with my practice. One thing I show people is the cholesterol molecule which is a double carbon ring that makes testosterone. One of my favorite stories, a gentleman came to see me and he said, “Oh, my doctor says I’ve got the lowest cholesterol he’s ever seen.” And I said, “Gosh, I bet you have very low testosterone.” He said, “Funny you should say that.” He said I had the lowest testosterone he’s ever seen too. So we know that cholesterol makes testosterone and the number I’ve seen it’s 140, some people say 160. If you have a cholesterol under 160, you can’t make your hormones because you need that double carbon ring building block as a steroid backbone to make all of your hormones.
So, I’m not against statins. There is a very small population of people who do benefit from cholesterol drugs, but it should not be in the water like I was told when I was a med school. The data looks like it doesn’t work very well for women, particularly post menopausal women. I refer you to Stephen Sinatra’s Cholesterol Myth book. We know it’s about inflammation not about cholesterol.
I think this whole idea of erectile dysfunction is that it’s this aging phenomenon we talk about, James, is that we’ve got men 55 years old that really are physiologically are 65 and 70 because of all the hormone disruption, the junk food they’re eating, they’re overweight, their blood sugars aren’t optimal. In my experience, I use very little Viagra and Cialis in my practice because we’re able to get people healthy and erectile dysfunction goes away. The quality of their sex life increases, their libido increases.
But again, I’m just consistently shocked how many people just accept that I’m 55 years old and sexually isn’t a big part of my life. I’m not that passionate about it and it doesn’t really work very well when I do it. And they’re 55 years old. And they think that’s the norm because that may be the new norm. But again, I think you’re going to see this flip and there’s a lot of smart educated people, I hope most of them are listening now and this is going to spread like wild fire. This is the cure.
That’s what’s also interesting, James. When we fix the gut, fix the liver, optimize the hormones, people will say, yeah, well, the fatigue I came in is better but I’m also sleeping better and my migraines are gone and my asthma is better and I’m happier and I’ve got more energy at work and I’m more in love with my wife and I’m exercising more and all these other good things happen, but you’re really fixing just one thing in that functional model because it’s all so systems related.
James Maskell: Yeah. That’s the systems biology coming through is like we’re not just managing a symptom better, we’re actually dealing with the underlying dysfunction. I think the other part of this evolution of medicine is moving from a symptom based approach to a cause based approach. You’ve mentioned the gut, you’ve mentioned the microbiome, you’ve mentioned toxicity, you’ve mentioned diet. One of the other ones that we talk about, those are the three, and stress obviously is another one. Do you want to just talk a little bit about, you talked about psychoneuroimmunology earlier. I know That’s a big effect on the endocrine system. Do you want to just talk a little bit about stress and how that sort of filters through to affect the endocrine system and everything else?
Dr. Mark Menolascino: Yeah, there’s been some great studies done. Some by Dr. Warner, Dr [Vogel 00:39:16], that looked at stress. What I tell my patients is I say, you know, stress is actually a good thing. If we didn’t have stress, we’d still be a single cell amoeba swimming in that pool of muck. Stress is what gets you out of bed in the mornings, it’s what wakes you up, it’s what motivates you. But you have to have stress that’s a passion, not stress that’s a poison. We always thought type A people were bad. I heard the story that the type A story came from an upholsterer in a cardiologist office. He noticed that the arms of the chairs he was having to upholster five times more often than he was the OB doctor down the hall. And that’s where this term was actually coined.
But it’s the type A stress people that are hostile and they’re angry and unable to express it. So being stressed by itself may not be such a bad thing, but it’s how you manage your stress. A great example is here in Jackson Hole, we’re blessed with great snow, we’re the best in America this year. But there’s ice on the ground and there’ll be a day where it’ll snow and all the trees are covered, it’s beautiful, but there’s some ice in one woman will walk in and go, oh my gosh, look how beautiful the mountains look, look how beautiful the trees are. I love it when it snows. The next person will walk in and go, oh, I’m so scared, I’m going to fall and break my neck on the ice. So the same external stressor has two totally different internal outcomes.
And so, I think it’s really about how you manage your stress, whether you do guided imagery, deed breathing. The yoga movement has probably been the most beneficial thing of anything in health in America. I tell all my patients to at least try it. So I think that whole mind body paradigm. I love the work of heart math with the heart rate variability. It’s an easy way to do biofeedback and to regulate your parasympathetic sympathetic balance. There’s a little portable things you can do. Even simple deep breathing.
I teach every single one of my patients how to breathe. I have them put their hands on their belly, tell them to take a deep breath. They all raise their shoulders and I say no, take a deep breath and push your belly out. It’s the first time they’ve ever belly breathed in their life. And I have them do it three times with each meal and practice, and whenever you have one of those phone calls or those conversations or anything that raises that stress level, go right into your deep breathing, do three deep belly breaths and you’ll find it just gets easier and easier.
But I think stress really chews up those hormones. I do tests on people, but I’ve been doing this long enough, and one thing I would caution the physicians and the clients out there is, there’s a lot of people doing the work that I’m doing that were in the ER or in the OR or were OBGYNs a week ago and went to a conference and learned how to do bioidentical hormone therapy over the weekend and are not prescribing you hormones. I’m not sure that that’s the best medicine. Even though it’s great that they’re making the transition, I’m fortunate that I saw this from day one before I even went to medical school. Did the dual masters, worked in PhD academics and have gone to all these conferences. I’m triple board certified. I’ve done my homework. I think if you can find more and more people who are certified to the Institute of Functional Medicine, to the A4M, you know they’ve done their homework and they’re not just someone who hung up a new shingle to try to reinvent themselves.
There’s a lot of not so great hormone therapy going on out there by people who don’t really understand it and they’re relying on compounding pharmacists to prescribe it. I think the compounding pharmacists, that group in general is very, very good. But again, I just kind of caution the physicians and the clients out there, find someone who’s done this that’s had one of the certifications, that’s done their homework, because I see a lot of people who are really overdosed on their hormones that really don’t need to be on as much as they are on.
James Maskell: I’m even seeing now on the subway in New York or everywhere, ads for people saying, have you been prescribed testosterone? Have you done this or done that. You might be eligible for a lawsuit or whatever. I think some people are realizing that this is obviously coming to the [inaudible 00:43:20], at least in the attention of the masses. I definitely appreciate you sharing that. It’s a tough situation because obviously, you know what, we’re going from one paradigm to a completely different paradigm. And there’s obviously going to be some stretchmarks in that movement. It’s exciting to see that doctors are sort of getting it.
I definitely have to agree with you that if you just understood the systems biology at a angle really, really well, it would help you to understand all of the other parts. Whereas if you’re just trying to do like basically allopathic medicine with the tools of natural medicine, whether it be bioidentical hormones or herbs or nutrition or whatever and you’re just doing the same, you know, understanding everything in the same paradigm but just using a different tool, it seems like that’s not really going to get us there in the same way. So it’s really a fundamental reeducation, isn’t it, for doctors to understand the body through this different lens.
Dr. Mark Menolascino: Yeah, it is. One of my favorite sayings is that all the internal medicine doctors think that people have reflux because they have too much acid and give them the little purple pill. All of the natural doctors think that they have too little acid and give them all BT and hydrochloric acid. well, they’re both wrong because not everybody has the same thing. You’ve got to personalize it for that. And it really approaches that systems.
It’s interesting you mentioned all the testosterone ads. There are all kinds of things over the TV about natural aids for hormones. They’re all bogus. I haven’t seen anything that really works. So I caution everybody not to use those. There’s a big concern right now about testosterone and heart disease and heart attack. And there is a VA study that was really poorly done, I thought, the age range of 18 to 64, they weren’t following red cell mass counts. But if you’re following hormone therapy based on the guidelines from one of the certified institutions, you really are doing safe therapy for people. I trained as an internist because I wanted to be able to quote the latest Jupiter crestor double blind placebo controlled multicenter international clinical trial, and I’ve kind of walked away thinking a lot of these clinical trials may not be so evidenced based.
Marcia Angell, who’s a former editor of the New England Journal Medicine, came out two years ago and said, you pretty much can’t trust most of what you read in the medical journals because of the bias. So I do think you want to practice evidence based medicine, but I don’t think you can plant your flag too high in any one hill. That was a quote one of my mentors gave me when I first started. I call myself an open minded skeptic. I don’t believe in alternative medicine. I don’t think alternative medicine works. That’s the stuff that you reach for when nothing else works. I believe in this functional, complimentary, integrative combination. Do good medicine first, but look at all the other options that you can personalize to the unique individual.
The thyroid is a great example. There’s a big controversy about whether it’s appropriate to let the TSH go below normal. Because when you use Armour Thyroid or compounded thyroid or anything with T3 in it, a lot of times the T4 and T3 which are your active numbers and you’ve got to follow the free form of it, not the total, they will look normal, but the TSH will be a little bit low. We were taught that that’s an osteoporosis and a Atrial Fib risk. Well that data came from cancer patients that were markedly suppressed. A recent study shows that may not so much be true. No endocrinologists wants to see a TSH so they’ll cut the dose in half of what the patient’s on. The patient will feel horrible, but their TSH will come back into the so called normal range.
So I think that’s one of those controversy in medicine we’re not really sure of. I personally think that if you have the TSH too low, then you’re missing something else. So I think you do aggressively treat people with thyroid that benefit from it, but I think you want to be cautious not to overtreat them. And if you are to the point of suppression the TSH, then you’re missing the adrenal or progesterone or the gut or one of the other parts of the symphony.
That’s just a little pro for the positions out there. And I know that’ll be a little controversial because a lot of people don’t even look at the TSH anymore in natural medicine. But if your TSH is low, your TRH is low. So your pituitary and your hypothalamus are both a little bit out of bounds and the conductor of the symphony may be a little confused.
James Maskell: We can’t have that, can we?
Dr. Mark Menolascino: We can’t.
James Maskell: You’re not making good music if the conductor’s confused. So Mark, let’s just take a step back now and look at sort of the future of what you’d like to see. What would you say is your finest and highest a wish or goal for this evolution of medicine? If you were to look back in 10 years and see medicine changing, what would you like to see? Take off your realist hat for a moment here and just maybe put on the rose tinted glasses and say, looking forward, what would you really like to see as far as medicine moving forward in the next few years here?
Dr. Mark Menolascino: I’d like to see chronic illness wiped off the face of the earth. I don’t know why we can’t use these functional medicine tools to do that. Because most chronic illness has its underpinnings in some functional dysfunction. And the tools and the knowledge are out there to find those and reverse it. You look at Mark Hyman did with the Saddleback Church and his blood sugar solution and the lives he changed just by changing how they interacted, how they exercise and what they ate. Huge amounts of weight loss, reversing diabetes, and again, those people, yes, they lost 20, 30, 60, 80 pounds, but their asthma went away. Their insomnia went away. Their relationships improved, their joint paint went away. So again, a lot of this is tied to that.
My other dream is that we get more than 10 minutes of nutrition in med school disguised as scurvy and rickets. So I think we’re starting to see that. We’re starting to see nutrition and functional medicine and integrative medicine being taught in the mainstream medical schools. I think if we can bring it side by side, like I said, for acute care medicine, acute care medicine works really well. But it’s about the chronic illness that the acute care medicine model not only fails, but it’s bankrupting us. I hope that we can have the least spent per person in the world on medicine and have the best healthcare in medicine. Like the Chinese doctors, they’re successful when their patients aren’t sick, not when they are sick. It’s a whole model of how we’re raising food, how we’re using medications, how we’re incentivized for procedures. The whole model has to shift. I think it’s going to be the patients that force the shift.
Do you really want to wait two hours to see your doctor for four minutes to get another prescription? Are you Willing to spend $150 to sit down with someone for half hour who works right on time, respects your time and actually gives you answers, gets to know you, has a relationship with you, and that can change the future of your health? I think you’re going to find more people are willing to do that. It’s gonna change the whole insurance model for this.
James Maskell: That’s another thing that came up a couple of times is for people to vote with their feet. Vote with their dollars and vote with their feet. It’s amazing how many people will sort of tell you that they disapprove of this or they don’t like this. You see that with like, a lot of people make fun of McDonald’s for instance, but they’re still serving billions of hamburgers every year.
It seems like in medicine, one of the themes that we’re seeing is doctors saying to patients, well, hey, I’m going to kick you out of my clinic if you don’t do this, if you don’t do that. I just see it the other way. Like if the patient’s in control of the process and they’re in control of who they’re going to see, have some standards for the kind of interaction you want to have and then vote with your feet if it doesn’t work. I think that doctors who aren’t getting the patient flow are going to start looking to see how they can offer better service and offer to add more value. And it seems like that would be a, could be a pretty successful driver of change.
Dr. Mark Menolascino: I think there’s two other pearls I’d love to share with you, James, and to our friends listening. One is vote with your feet but also vote with your fork. Why is a two liter bottle of soda pop 99 cents but a bush or organic broccoli is $5. That’s just wrong. That’s at a fundamental level. So voting with your fork when you’re able to make sense.
The other thing is in medical school, they taught us to motivate our patients by fear and guilt. If you don’t do this, that will happen. Well, you know, that’s not a good motivator. I think what our job is as the new generation of physicians, let me provide you with information to empower you with knowledge, to encourage you and help you to change your behavior. That’s really at the core of what functional medicine does. It gives you a new tools to give you new information to provide you with knowledge to help you and coach you and walk with you to change your behavior to get healthier outcomes.
James Maskell: That’s a massive theme actually of the whole summit is that empowerment movement. And yeah, it’s so true that guilt and fear and shame only works in an acute care model really. In this chronic model, you’re more likely to start feeling depressed and we know what that’s going to get you, right?
Dr. Mark Menolascino: Absolutely. Absolutely.
James Maskell: What are some of the strategies that you have used with patients to shift that, because they’re probably used to being told off by their doctor. We had this sort of patriarchal medical system where like the doctor’s like your dad and tells you off if you’ve been naughty. It seems like that’s definitely on the way out. You said standing hand by hand, walking side by side with people. What does that look like clinically? You’re an MD, you’re a physician, you’re working in a clinical setting. What does that look like for your patients? What difference would patients notice if they came to see you compared someone doing conventional endocrinology or internal medicine?
Dr. Mark Menolascino: It’s interesting you say that. One of my clients saw an endocrinologist and the endocrinologists didn’t even make eye contact during their 10 minute conversation. They didn’t touch them and they didn’t make eye contact. The comment I hear the most from my clients is that I listen. The studies say that the average doctor interrupts the patient within seven seconds of them talking. My job is I tell people, we start, tell me your story. Let me learn about you. And I sit back and listen. Sometimes it’s five minutes, sometimes it’s half an hour. But so many people have never been heard, particularly the female patients.
In trying to connect, ask about their family life, their passions, what’s important to them. It’s a lot like sales. To sell someone a microwave, you’ve got to know why they want it. It’s a hot button. Well, what’s your hot button, James? It’s your daughter. What’s my hot button? It’s my kids. It’s what’s your hot button that I can help stir with you and empower you with that you’ll help make the change. Not sit in the big chair and point at you and tell you what to do.
That’s another real pearls is, I think William Osler, one of the famous doctor said, shut up and listen and your patient will tell you what’s wrong with them and how to fix it.
James Maskell: Do you think that’s true? Do you think most people sort of know what the core starting point their dysfunction is if you take enough time and you listen and you asked the right questions?
Dr. Mark Menolascino: Well, in functional medicine, we have a timeline that we go back to the very beginning and look at the antecedents, triggers, and mediators to see when this started and what might have triggered it. A lot of times, I’ll kind of at the end of our session say, what do you think is going on? I know you’ve done your homework, and most people come in with a big pile of stuff and they’ve been on the internet. They’re pretty smart. They’ve looked at a lot of things. A lot of times they’ll know.
A lot of women come in and they go, I know I have a thyroid problem. I’ve seen five doctors, they tell me I’m fine. I’ll examine them, [inaudible 00:55:24] and go, you know what, I think you have a thyroid problem. I think you’ve been right this whole time. We treat them, their world changes. So a lot of times, my patients’ intuition, particularly a woman’s intuition is the smartest person in the room. You always should listen to that intuition, your own as well as your patients and you’ll never go wrong.
James Maskell: That’s so important. I’ve heard a number of doctors say over time that what you’re really talking about there is love. You’re talking about communicating that and the best thing that you can do to love someone is to listen to them. And it sounds like that’s what you’re talking about.
Dr. Mark Menolascino: I think you’re right. Dean Ornish says, the most powerful thing he has in his tool box is the power of love. That’s why the group support with the Saddleback Church, the group support and his reversing heart disease was probably the most powerful thing there. It wasn’t the broccoli, it wasn’t the walking, it was that support. That’s why women live longer. They have more social support than men do and that’s been proven. So I think the power of love is underappreciated and not as easily dispensed. If your patients know that you truly care about them, they will get better.
James Maskell: Well, that sounds like, that’s definitely a warming and exciting message for the future of medicine because we’re all capable of doing that. It’s free, it’s easy and everyone knows how to do it. I heard a guy from TEDMED talk about Wellth, W-E-L-L-T-H. This sort of value that’s in this community, that from the community, the help that you’re getting from other people in your community. That is really the value that comes through that. And one part of it is the doctor-patient relationship. Other part is the patient to patient, the peer relationships. I think if We could focus on that, I think we’d make a lot of progress really quickly.
Mark, I really want to thank you for your time today. I think we’ve covered a lot of ground today. We’ve been through conventional endocrinology, the new understanding of endocrinology. We’ve looked at the relationship with a gut. We’ve looked at men and women, we’ve looked at stress, we’ve looked at toxicity. One of the things that you’ve really helped me to do and I just want to honor your process, my business Revive Primary Care. We’ve focused on educating patients about these four causes of chronic disease that are in the bounds of patients to take care of.
We mentioned diet, stress, toxicity and sort of bugs and the microbiome. These are things that patients can really take care of. So much of my journey has been learning from you and other people who have really outlined some of the simple truths that underlie this format of medicine. I just want to appreciate you for the work that you do and the impact that you’ve had on my life thus far. And I know that look, we’re just getting started. I hope that by the time we come back for Evolution of Medicine number two next year, we will have seen some of the shifts that you’re talking about and some acceleration of this evolution of medicine. It’s been great to have you here today. I really appreciate your time. Any last thoughts you’d like to share with the world before we close out here?
Dr. Mark Menolascino: Well, you know, I started talking about my father and his passion for medicine and he gave it to all of us. He would come home from these long 12 and 14 hour days energized. And my kids see the same thing with me. I come home from my job energized because I get excited and passionate about my relationships with my patients. You don’t see that with other physicians that are doing regular primary care. And so again, bringing your passion and sharing that energy with people, it actually makes your job full of love and joy and it makes it easy.
I really honor you for what you’re doing. I think spreading this message, and you will see this transition happening and next year will be even bigger and bigger.
James Maskell: Thank you so much, Mark. Thanks so much for your time. Thanks everyone for being on the Evolution of Medicine Summit. We’ve got some great sessions coming up. Thanks so much Mark for today and we’ll see you next time.
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