The Estrogen-Gut Connection Every Woman Should Know with Kimberly Kushner

What if bloating, low libido, painful sex, ⁓ hormone changes, ⁓ mood shifts, what if all of these things are not separate problems, but they’re connected signals from the body? In this episode, we’re talking about the gut hormone sexual health connection, how digestion affects estrogen metabolism, for example. ⁓ Some people recognize that connection as ⁓

something called the estrobolome, or how does that interact with inflammation or energy, desire, vaginal and pelvic health, and really how women can begin to understand bloating and GI issues, not just as some kind of inconvenience or something that they have to put up with, but as information to be a catalyst for change. Today, Kimberly Kushner is back with us, and this time we’re going deeper into the terrain. So many women are navigating quietly.

Kimberly Kushner (00:46)

and decent.

Dr. Ginger Garner PT, DPT (00:57)

all these gut symptoms, hormone shifts, intimacy, and the search for real answers. So welcome back to the pelvic floor. I am so glad that you’re here with me again, Kimberly, welcome.

Kimberly Kushner (01:09)

Thank you so much for having me. It’s such a pleasure to be here.

Dr. Ginger Garner PT, DPT (01:13)

Yeah, you know, for those of you listeners who may have not heard Kimberly’s first episode, I just want to reflect back on that a little bit and give you kind of a high level overview. Kimberly Kushner is a naturopath and clinical nutritionist. She has over 15 years of clinical experience, blending evidence-informed holistic care with deep lived experience. She’s navigated more than 26 years with endometriosis along

Kimberly Kushner (01:15)

you.

Dr. Ginger Garner PT, DPT (01:42)

complex chronic conditions like POTS and more recently a diagnosis of HEDS, what we know as hypermobile Ehlers-Danlos syndrome and other related comorbidities. And she’s really dedicated to her work to help women make sense of their symptoms and really feel supported with practical sustainable strategies. Through her practice, she provides comprehensive care for women with endometriosis and the POTS MCAS EDS trifecta, which makes my

eye twitch, right, to think about what these women have to go through. ⁓ And putting a special focus on the interconnected roles of nutrition, hormones, the nervous system, and emotional well-being. ⁓ Kimberly is a fellow mother to three boys and brings a grounded, compassionate approach. There’s a, I am told there’s like a special place up there for moms with multiple boys. ⁓

Anyway, she works on that compassionate, with a compassionate approach and really meets women where they are, especially, especially, especially, and this is all too common when women have felt dismissed or overwhelmed by the complexity of their health issues. So welcome back, Kimberly.

Kimberly Kushner (02:50)

Mm-hmm.

Thank you so much, Ginger.

Dr. Ginger Garner PT, DPT (02:59)

Yeah. All right. Let’s just dive right in there because for the listeners who didn’t listen to your first one, I’d say go back and listen to your first episode. It really focuses on endometriosis. And we are going to focus on that today, but there’s this larger thing looming and it’s been on our horizon. I remember the first time I really considered or was introduced to the term gut microbiome back in 2012 or so.

Let’s start with that big picture. Why gut health matters for hormones, et cetera, no matter what age someone is. So let’s just kind of lay out a case. Let’s say a woman comes in and you suspect there’s hormone issues. She has mood changes, cycle changes, low libido, painful periods, perimenopause symptoms. Why would you look at the gut?

Kimberly Kushner (03:51)

So your gut has a direct effect on your immune system and on your hormone detoxification, on ⁓ the way you synthesize nutrients. So it has such a significant flow on effect on how she may be making and clearing hormones, how her immune system is affecting her brain, neuroinflammation, there’s a direct gut.

brain link as well. Your gut talks to your brain, the bacteria in your gut can influence the signals that are getting sent up to your brain. So these are just some of the ways that your digestive and your gut health in general can affect a woman with the things that you mentioned. And it’s quite a lot in many ways. Yeah.

Dr. Ginger Garner PT, DPT (04:45)

It

is a lot to unpack. so that gut hormone connection is something I think that either doesn’t get talked about enough or kind of, it just gets kind of glazed over like, yeah, we’ll eat better and you’ll just feel better, right? There’s nothing specific. So when we look at, if you can, in a way that listeners can use,

Kimberly Kushner (05:03)

Yeah.

Yeah.

Dr. Ginger Garner PT, DPT (05:16)

How does your ability to digest something, the status of the microbiome once the food gets there and lands, inflammation and estrogen metabolism, how do they end up interacting in the gut?

Kimberly Kushner (05:18)

Mm-hmm.

Mm-hmm. Mm-hmm.

Yeah, so when we think about the way that your ⁓ digestive system affects your hormone metabolism, it’s very, very significant. So when we think about, for example, our primary estrogens, so you have E1, E2, E3, right? These are your main estrogens. Now, they all go through three different phases of detoxification, which involves your liver and then your bowels.

Also your gallbladder actually. So it goes through first phase of detoxification through your liver. ⁓ Your liver has multiple, I kind of use the analogy of imagine a highway and there are lots of different lanes and all these lanes are responsible for different substances in the liver that the liver is responsible for detoxifying. So hormones kind of have their own lane. And so the liver deals with the hormones initially. And then,

Eventually it goes through phase two detoxification as well. ⁓ And then after that, get the estrogens get packaged up nicely and essentially dumped into your intestines. So when this happens, it undergoes a process called conjugation. So the estrogens are conjugated and packaged up nicely. Now, when they reach your intestines, it depends on a ⁓ it’s reliant on a family of

microbes that live in your gut called your estrobalome or estro- depending on how you pronounce it, estrobalome ⁓ and they release an enzyme called beta-glucuronidase. Now this enzyme can unpackage that nicely packaged up estrogen, okay, and what happens then? Well we have the potential of what we call enterohepatic

recirculation, meaning that estrogen that was packaged up and conjugated nicely as it went through phase one and phase two of detoxification through your liver now reaches your intestines. And if you’ve got excess beta glucuronidase, it pulls it apart and then you can reabsorb it back into your bloodstream. And then you get all this estrogen eliciting its pro-estrogenic effects systemically. So you’re not clearing it as effectively. And that involves, like I mentioned,

this group of microbes called your estrobalone, ⁓ which produces this enzyme. Now, in a dysbiotic gut environment or a gut microbiome that is dysbiotic, meaning, you know, out of whack, out of balance, too much of certain microbes, not enough of others, lots of opportunistic or maybe even pathogenic microbes, you can get this very dysbiotic or imbalanced microbial picture.

which then predisposes you to excess production of this enzyme, ⁓ which then makes you more likely to recycle this estrogen back into your bloodstream.

Dr. Ginger Garner PT, DPT (08:36)

Yeah, yeah, it’s one thing that I keep a ⁓ close eyeball on when I’m watching patient labs is that presence, if they do gut testing ⁓ in the practice of beta-glucuronidase. describe then with phase three metabolism, because we talked about, that means you’ve got to have a healthy liver, right, doing its job. It can’t be distracted with other things.

Kimberly Kushner (08:50)

Yeah.

Yes, we don’t want the

liver overburdened. So when we look at conventional labs like your liver function tests and we look at liver enzymes, they may be perfect. They may be well within normal range. That does not give us an indication of how your liver is actually detoxifying though. It just says, hey, there isn’t an excess amount of liver enzymes in your bloodstream.

Dr. Ginger Garner PT, DPT (09:08)

Mm-hmm.

Kimberly Kushner (09:32)

great, so there is an inflammation and popping of these liver cells releasing enzymes everywhere, but it doesn’t mean that you’re optimally detoxifying ⁓ through your liver. There are tests that you can do, ⁓ but I typically kind of look at the ratios at which these primary estrogens get converted into their metabolites, into their phase one and phase two metabolites, and there are more…

⁓ specific functional tests that do that, like the Dutch, for example, which I see plenty of. ⁓ And that can kind of give you a better indication. So liver function is very important.

Dr. Ginger Garner PT, DPT (10:04)

Yeah.

Right, yeah, is,

because honestly, the price of lab tests just continue to kind of add up  when you start to do all of these things. So yeah, I think looking at metabolites are really important and the Dutch test is ⁓ a good way to do that ⁓ so that you can see if the metabolites are too high and those can be, you know,

Kimberly Kushner (10:21)

Definitely.

Dr. Ginger Garner PT, DPT (10:39)

brought down in several different ways and should because there’s also a genetic connection to that as well as in terms of ⁓ how methylation is happening or DNA preservation. So things that you inherited that might be you got both bad genes from a parent or a homozygous SNP isn’t expressed. it’s a deep well, isn’t it?

Kimberly Kushner (10:46)

Absolutely.

Yes.

Yeah. So, I mean, the big buzzword is like your MTHFR genes, right? At the moment, everyone’s talking about it. So that’s just one element of it. There’s also, when we look at like phase two metabolism, there is an enzyme called COMT, which is responsible for your phase two estrogen detoxification. And women can have really fast comped or slow comped.

Dr. Ginger Garner PT, DPT (11:08)

Mm-hmm.

Thank

Kimberly Kushner (11:30)

⁓ And if it’s slow, then you’re more likely to have a buildup of estrogen and catecholamines like adrenaline, noradrenaline and dopamine, meaning, ⁓ you fit this picture of very estrogenic symptoms and anxiety, for example. You’re talking about the mood changes. ⁓ And that’s where more specific and personalized genetic

the genetic component comes into it. yeah, it’s, it’s pretty, it’s significant. It all, it all contributes to how you are metabolizing and then how you feel, obviously, and your symptoms.

Dr. Ginger Garner PT, DPT (12:12)

Yeah. And that’s why I think that the distinction needs to be made when we’re talking about labs, because there’s such a, kind of a swell of negative, you know, negative tsunami, if you will, of, labs don’t matter, don’t pay attention to labs, it’s only how you feel, right? And I think it can easily get confused between blood serum labs, right, where maybe someone visits a gynecologist and they’re like, we don’t do labs.

maybe we’ll do serum, but they’re confusing the difference between something like the Dutch, which is a urine test versus a blood serum test. And the blood serum isn’t going to measure a metabolite, whereas the urine does. I think that’s an important distinction because people are coming in, they’re sitting down in my office and going, well, I was told, or they’ll see it on social media. don’t measure hormones, it doesn’t matter. But they’re talking about metabolites.

Kimberly Kushner (12:54)

Yes.

Yeah.

Yeah. So your bloods will show you a snapshot of what’s happening then and there. And it can still be utilized as part of your plan. You could do a blood test at the start of your period, like on day two, day three. Then you can do one like a week post ovulation and just see how your progesterone is tracking. But again, it’s not showing us how you are metabolizing, ⁓ which can

you know, if it’s, if it fits, if the bloods give you enough information to move the needle, then that’s wonderful. But in complex people, often you need to dig a little bit deeper.

Dr. Ginger Garner PT, DPT (13:50)

Yeah, and that is definitely who our population is. That’s who we’re talking to. ⁓ Women with endometriosis who are struggling with a much more layered ⁓ complex situation. And that leads us to kind of phase three metabolism because there’s so many things that happen when someone has endometriosis. It’s not just the bloating and we’ll get to that in a second, like bloating and pelvic pressure and what gets missed. But in phase three metabolism,

Kimberly Kushner (14:01)

Yes.

Thank

Mm-hmm.

Dr. Ginger Garner PT, DPT (14:19)

we have this phenomenon of constipation. know, if someone’s constipated and they’re not digesting things well, or they have food triggers, right, ⁓ that haven’t been identified, tell, explain a little bit to the listener about phase three metabolism and why it’s so important that constipation is not present, which it all too often is.

Kimberly Kushner (14:29)

Yes.

Yes. Yeah. Yeah. And then I’ll layer

in a layer in if anyone listening is interested in the mass cell and EDS side of it too and parts. So yeah, so obviously when the nicely packaged up estrogen gets dumped into your intestines, you want to clear that with as little unpacking as possible, right? We want it to flow through and then be excreted.

Dr. Ginger Garner PT, DPT (14:47)

yeah, absolutely. That’s right. That’s next up.

Kimberly Kushner (15:06)

and reduce the recycling. But if we have constipation, A, it stays longer there. And B, if you are constipated, may have some dysbiotic, ⁓ you may have a dysbiotic microbiome picture, ⁓ which can make you more likely, like I said, to produce excess beta-glucuronidase. And then when we think of  where your mast cells are located

in the lining of your colon, mast cells don’t like pressure. So if you’re constipated and they’re pushing against the wall of your colon, your mast cells are going to degranulate and it can trigger more mast cell symptoms. It can trigger more visceral hypersensitivity. Sorry, one second. Pain, cramping, all of that. And then if you’re also reacting to foods,

For example, someone who’s not a celiac, but they eat gluten and they get more constipated, ⁓ that can further compound the issue. And then when you have obviously EDS, your connective tissue or your peristalsis, which is the muscular contractions of your intestine, can be compromised. And when we’re dealing with POTS, we know we’ve got low blood volume, just to complicate things more. your body is, yeah, so your body is going to be…

Dr. Ginger Garner PT, DPT (16:26)

just to add another layer, yeah.

Kimberly Kushner (16:30)

⁓ Going okay. I need to prioritize blood volume. So where am I gonna take fluid from? I’m gonna take it out of my bowels because that’s where water reabsorption happens. So you then get more constipated. So it’s so important to if you have the trifecta be hydrated so important to stay hydrated to not get fecal loading and not get constipated and not trigger the excess degranulation of mast cells as well as get all the estrogen out as effectively as possible because

constipation can then predispose you to SIBO as ⁓ bacteria moves backwards and upwards. So it is complicated. And then if you’ve got the excess beta glucuronidase, that will cause more mast cell symptoms because the estrogen triggers off the mast cells. So you can see the importance of, yeah.

Dr. Ginger Garner PT, DPT (17:16)

Yeah. Yeah, it is.

It’s

like a cyclone, you know? It’s not just a single snowball rolling down the hill and getting bigger. You know, it is a multimodal ⁓ thing.

Kimberly Kushner (17:30)

Yeah. And so when I see someone,

always have to take into consideration all these components of it’s not just constipation because there’s a lack of fiber in water. Typically it’s hardly ever that it’s so much more complex than that. It’s peristalsis. It’s, you know, if there is a neuro, if there’s neurological dysautonomia, like POTS, ⁓ involvement, there’s probably, you know, dysautonomic.

Dr. Ginger Garner PT, DPT (17:42)

Correct. Yeah.

Mm-hmm.

Kimberly Kushner (17:57)

stuff going on there that’s affecting the peristalsis and then the mast cells and then the fecal loading and then the dehydration and then the fiber and the food and then if you have MCAS the food’s going to be an issue depending on how sensitive you are.

Dr. Ginger Garner PT, DPT (18:14)

So I

yeah, I think the takeaway is that A, you can have identified all your food triggers, like sensitivities, allergies. You could be hydrating like a champion, right? You could be eating your plant-based diet and fiber and doing really well, and that still may not be enough, which B, emphasizes the importance of personalized

Kimberly Kushner (18:30)

Yeah.

Dr. Ginger Garner PT, DPT (18:42)

prescriptive care instead of just a generic try this, you know, type of thing approach.

Kimberly Kushner (18:44)

Yes.

Yeah, yeah, yeah, yeah.

So if you’re having lots of fiber and also not enough water that can constipate you depending on the fiber that you’re taking in as well. It just gets, yeah, it can – constipation can be very complicated and I see it complicate things so much. So I usually like using calcium deglucarate if this is the case. ⁓ Now there are stool tests that show us

Dr. Ginger Garner PT, DPT (19:10)

Mm-hmm. Yeah.

Kimberly Kushner (19:16)

⁓ whether you have excess bacterial strains that are producing beta-glucuronidase, which if you need a little refresh, it’s that enzyme that is produced by the estrobalone, which is responsible for ⁓ unpackaging that estrogen and then you get more circulation. So calcium deglucurate is a nutrient that can

block or hinder the activity of that beta-glucuronidase. So if you’re very estrogen dominant and you’re constipated and you have excess strains that are producing this beta-glucuronidase, then calcium deglucurite could be a good ⁓ inclusion for you.

Dr. Ginger Garner PT, DPT (20:01)

Yeah, it’s a brilliant little supplement ⁓ for so many people. And that’s across the lifespan too. We’re not just talking about estrogen dominance for the perimenopausal or menopausal person. This could be at any age that someone needs to inhibit Beta G and bring that down. Yeah.

Kimberly Kushner (20:19)

yeah.

Yeah, yeah,

absolutely, absolutely. So it really is like a whole system that we have to support ⁓ in the person who is dealing with all this straight from, you know, all the way from the mouth to bowel movements.

Dr. Ginger Garner PT, DPT (20:41)

Yeah, which is, it brings up an important little snapshot because, okay, so how many women, doesn’t necessarily mean you have endometriosis, but it definitely does if you have endometriosis, how many women have bloating? Super common in women with pelvic pain or endo, perimenopause, chronic stress. So what are the most common root…

Kimberly Kushner (20:51)

Thank you.

Hmm.

Dr. Ginger Garner PT, DPT (21:10)

Causes you would go to because I think bloating is probably one of the most common complaints that  women talk about

Kimberly Kushner (21:17)

yeah, I see it in like 90

% of patients. Like almost every single person is bloated. ⁓ Are you asking what the most common causes of bloating is?

Dr. Ginger Garner PT, DPT (21:28)

Root causes, yeah, when you’re thinking about, you know, someone comes in

and they already have something, maybe they have endo or maybe they don’t, it’s not identified, but they have pelvic pain or they’re perimenopausal or maybe they’re just absolutely overstretched and stressed out. What are the most common root causes that you just kind of go to and you’re thinking about differential diagnosis?

Kimberly Kushner (21:38)

Yeah.

Yeah.

I’m always thinking about that intestinal dysbiosis. Absolutely thinking about the intestinal dysbiosis and also constipation, obviously the fecal loading component of it. People may have, may be constipated without realizing they’re constipated. That’s another thing. Unless you’re doing like a Bristol number four regularly. ⁓

Dr. Ginger Garner PT, DPT (22:06)

So true.

Kimberly Kushner (22:13)

people who are, you know, fluctuating. And if you don’t know what that is, look up the Bristol stool chart and then you’ll know what I’m talking about. yeah. You may be fluctuating between, you know, and this is that label, the IBS label constipation, diarrhea, you’re probably constipated. yeah, so constipation, dysbiosis, food sensitivities, MCAS.

Dr. Ginger Garner PT, DPT (22:20)

We’ll put the link in the show notes.

Kimberly Kushner (22:44)

And then there’s the more tricky dysautonomia, EDS, connective tissue overlap where peristalsis is compromised.

Dr. Ginger Garner PT, DPT (22:53)

Yeah. And I think that you brought up a really important issue that I just want to like illuminate one more time before I go to my next thought, which is people can be constipated and they don’t know it. If I just ask someone simply clinically, are you constipated? I’d say most people would say no. But if I start to describe what constipation could look like, which could mean you go every day and you’re still constipated, right?

or someone has feelings of incomplete emptying throughout the entire day, right? They could still be constipated if they have that situation. So I think that’s something to just point out. People maybe have a definition of constipation that isn’t maybe quite up to date.

Kimberly Kushner (23:43)

Yes, yes, you don’t have to not be going for 10 days to be constipated. And I see it, I see it on like ⁓ abdominal, like I see it on an MRI, the endo MRIs. You can see there’s feces in the colon. ⁓ There’s like a backup and they’re not feeling constipated. So those are hints as well when you see it in imaging.

Dr. Ginger Garner PT, DPT (23:48)

Right, yeah.

Mm-hmm.

Yeah, absolutely. It’s, yes, definitely. And I do, know, musculoskeletal ultrasound imaging. That’s easy to see on a trans abdominal image, transparenial image. You can see the diameter of the bowel. So let’s talk a little about symptomology because I think it can span so much and you probably have a slightly different perspective than I do on how bloating impacts

Kimberly Kushner (24:11)

You can see it in x-rays, yeah.

Yeah.

you

Dr. Ginger Garner PT, DPT (24:40)

⁓ Well, everything in terms of pelvic floor, bladder, sexual comfort, et cetera. How do you see that presenting nutritionally when someone comes in and goes, God, I’m bloated. What are they going to complain about?

Kimberly Kushner (24:41)

Yeah.

everything you mentioned, clothes not fitting, ⁓ intimacy, like you mentioned, sexual health, ⁓ appetite, like if you’re bloated, you’re going to not have a great appetite. And then, you know, more nutritional deficiencies, ⁓ lots of pain, it overlaps with the, like the pelvic pain as well, because there’s pressure, there’s lots of pressure, ⁓ lower back pain. ⁓

Dr. Ginger Garner PT, DPT (24:57)

Hahaha.

and appetite.

Mm-hmm.

Kimberly Kushner (25:25)

headaches, fatigue, all of it. ⁓ It’s gonna have a systemic effect on the individual for sure.

Dr. Ginger Garner PT, DPT (25:33)

Yeah, I think it’s really, really important for people to realize that. And I also see the interaction between the bladder and the position of the bladder because people with hypermobility, particularly women with hypermobility, ⁓ can have a hypermobile bladder or bladder neck that impacts bowel function or they have hypermobility in the bowel.

that’s going to create a bladder urgency frequency like going to the bathroom more often or having a really hard time emptying because those of you watching on YouTube, you can watch my my hands as the model because the bladder, if this is the anorectal canal, the bladder moves so much, it actually compresses and moves into the bowel and prevents emptying.

Kimberly Kushner (26:18)

you

That’s so interesting.

It’s so interesting. What were you saying just a little bit earlier about the bladder neck?

Dr. Ginger Garner PT, DPT (26:29)

Yeah, I see, let’s see, let me grab my model. So if you’re watching on YouTube, or if you’re not, you can stop and go watch on YouTube. So the position of the bladder, if I bring up all my parts and pieces here.

the bladder neck should sit a certain level above what we call the pubococcygeus line or the line between the pubic bone and the tailbone essentially. And so there are, in research we have standards for that. So that’s what I measure that often is how high the bladder neck sits above that PC line. And if it drops too far, a woman is gonna pretty much be guaranteed leakage, unfortunately. But also if it glides too far posteriorly this way,

Kimberly Kushner (27:05)

Right.

Dr. Ginger Garner PT, DPT (27:16)

more than 20 millimeters is the cutoff, and I measure that as well, then it can end up dropping so far that it impedes bowel emptying here on the anterior wall of the rectum. Yeah.

Kimberly Kushner (27:19)

you

Gotcha, gotcha. Okay,

that’s really interesting. So obviously in someone who’s hypermobile, who may have had, you know, a vaginal delivery or multiple deliveries, you can imagine how that whole area could be more mobile.

Dr. Ginger Garner PT, DPT (27:52)

Right, definitely compromised. I mean there are some clinical signs that we have, you know, in terms of like intravaginal. So I’ll go back to my model here with the bladder and the rectum with the vaginal canal in middle. There’s a fascial plane in the front and a fascial plane in the back. And those fascial planes in someone with HEDS or multiple births, one or the other, and, you know, of course, if you’ve had both, oh, goodness, that can be compromised.

Kimberly Kushner (28:15)

Yeah. ⁓

Dr. Ginger Garner PT, DPT (28:22)

So the clinical sign that I would look for intravaginally is if I’m doing an intravaginal, you know, pelvic exam, I will feel the rugae or the kind of quilt stitching on the top anterior wall. If that’s present, then that’s one fascial plane that I can consider that is more intact, but that doesn’t account for all of the fascial planes, the other fascial plane in the front. And then you can’t really determine that posteriorly.

Kimberly Kushner (28:44)

Okay.

Dr. Ginger Garner PT, DPT (28:49)

But I can appreciate it on real-time imaging to see actually where they move. And that’s where functional or what’s called dynamic, you know, other people call it real-time imaging really makes a difference. Different positions, asking them to do different tasks and then seeing how much that moves. Yeah.

Kimberly Kushner (28:59)

Mm-hmm.

Yeah, so interesting.

then you, you know, as you’re showing us that on your models, I’m thinking about endometriosis, lesions and adhesions and frozen pelvis, just moving things around. And I can, yeah, I can definitely see how bladder functions impacted how ⁓ bowel movements are compromised and how endo causes constipation.

Dr. Ginger Garner PT, DPT (29:24)

Definitely.

Kimberly Kushner (29:37)

from a um physical standpoint with nodules or lesions that are hindering. ⁓ Yeah.

Dr. Ginger Garner PT, DPT (29:45)

Yeah, biomechanically,

there can be a lot happening there, even when we’ve addressed everything else, which is why the conversation with you is essential because as clinicians, of course we have to rule out all of those things, right? We have to rule out the gut dysbiosis. We have to rule out fascial problems, the biotensegrity. We have to rule out biomechanical issues.

We have to rule out nutritional issues. There’s so many facets of this that make it complex that I think it’s a hopeful message though. It’s that if you have pelvic pain, don’t stop at a single answer. Visiting a gastroenterologist is not gonna give you all of your answers. You’re going to need to, a gynecologist, a urologist, a urogynecologist, still, you’re…

Kimberly Kushner (30:23)

Yes.

Yes.

Dr. Ginger Garner PT, DPT (30:40)

you deserve more than just seeing those few practitioners. Everyone needs to be working together because there are answers to what’s happening.

Kimberly Kushner (30:49)

Yeah, yeah, and it’s so hard because it is very complex and no two people are exactly the same either.

Dr. Ginger Garner PT, DPT (30:57)

Yeah, and I think that kind of answered my next question I had thought about, which was, gosh, what do we wish more women knew about constipation, motility, and hormone balance? Yeah, and one of the things that I often talk to patients about too, and I want to get your input on this, is when someone has complex pelvic pain. So let’s just say they have that trifecta. They have POTS, they have ENDO, have, maybe they have MCAS too

Kimberly Kushner (31:08)

Yeah, all of that.

Dr. Ginger Garner PT, DPT (31:27)

and HEDS. There’s a difference between motility of the gastrointestinal system and mobility. Because the abdominal wall can, from my perspective, this is biomechanical, the abdominal wall can be held so rigid from pain or guarding or that they lose that motility, but at the same time with HEDS,

Kimberly Kushner (31:37)

Yeah.

Dr. Ginger Garner PT, DPT (31:55)

They don’t have normal motility anyway, so they can end up almost like in a gastroparesis type situation where their peristalsis isn’t normal or the movement ⁓ of the intestines are not normal. Tell me a little bit about your experience with that.

Kimberly Kushner (32:06)

Yeah.

Okay.

I can totally like, as you’re

describing this, I’m like, yup, yup, yup. I have such intense guarding in like, it almost feels like trigger points in your abdominal muscles because you’re not stable and you’re using, you know, you’re weak, your pelvic floor is weak and your core is weak and you’re using all the wrong bits and pieces to stabilize. ⁓ Thankfully, I’ve been really on top of trying to be on top of diet to assist with

Dr. Ginger Garner PT, DPT (32:17)

haha

Mmm.

Kimberly Kushner (32:42)

gut motility and I use herbs and nutrients and whatnot. ⁓ But I do see motility become compromised due to mobility. And then that’s when I go, well, obviously it’s out of my scope. I’m not treating the whole person from a musculoskeletal physical therapy perspective, but I guess that’s where you need to go. ⁓ And this is the journey that I’ve walked. You where are

There are issues like you see people with, you know, everything from like scoliosis to compressions, head and neck compressions and vestibular issues. So it’s like that proprioceptions affected balance, ⁓ stability and all of that. So you’re just using all the wrong things to try and stabilize. And I guess you’d need to figure out what is contributing to that state in the first place. And it’s usually multiple things, which makes it hard. So yeah.

Dr. Ginger Garner PT, DPT (33:36)

Yes, yeah, it does.

Kimberly Kushner (33:39)

So hard. Yeah.

Dr. Ginger Garner PT, DPT (33:39)

And it takes a team approach. mean, I know we share several patients. We co-treat a lot across oceans really because there’s not a lot of people who really are specializing in this. We need more clinicians that do it. think access is a real struggle for people to build the team that they need. One of the things that I wanted to bring up

Kimberly Kushner (33:49)

Yeah.

Absolutely.

Dr. Ginger Garner PT, DPT (34:05)

which is kind of what the whole season has been focused on. So I want to circle back to this, is this aspect of sexual health and the gut hormone access and like libido, for example. Let’s just start there. Low libido is often, well, A, women don’t want to talk about it. Men can talk about it and they’ll immediately get handed some testosterone or whatever it is that they need. But

Kimberly Kushner (34:14)

Mm-hmm.

Yeah.

Dr. Ginger Garner PT, DPT (34:34)

everything is so incredibly difficult for women to access that oftentimes they don’t even approach it. They don’t even talk about it. They don’t even think they have a right to talk about low libido as if that’s just an optional thing, right? So it’s often treated like a relationship problem. you just need to go talk it out. No problem. Or it’s a mindset problem. you’re just not thinking about this correctly. Or it’s just a psychological problem. you have anxiety. Just here.

Kimberly Kushner (34:43)

Mm-hmm.

Yes.

Hmm.

Dr. Ginger Garner PT, DPT (35:03)

take some meds. ⁓ Nevermind that a lot of those meds, psych meds do have low libido as a side effect. Yes. And they’re being prescribed them and not even considered that. Yes, the irony is so thick. Or here’s another good one. it’s just age. You you just gotta roll with that. It’s just perimenopause. Perimenopause, there’s nothing you can do about it. And so I just wanna go, ⁓ Lord, full stop, okay.

Kimberly Kushner (35:09)

sexual side effects. Yeah, exactly. The irony. Yeah, it’s hard.

Hmm.

Yeah.

Dr. Ginger Garner PT, DPT (35:31)

So from

a naturopathic whole body perspective, what are some of the physiological reasons that you see libido can decline?

Kimberly Kushner (35:39)

Something that I am seeing a lot lately in clinic is low testosterone in women. Like really, really low testosterone in women. And I believe in my clientele that when we’re looking at endometriosis, we know there’s an upregulation of aromatase activity. Aromatase, for those of you who are not familiar, is an enzyme that converts

Dr. Ginger Garner PT, DPT (35:48)

Yeah.

Mm-hmm.

Kimberly Kushner (36:06)

your androgens, so your testosterone, into estrogen. And we know that this is a process that happens naturally, but in endo, the endolesions themselves can do this. So this is how they create their own estrogen. But I think it’s upregulated systemically as well, because I’m seeing really, really low test. And usually we see low test, normal high estrogen. Perhaps aromatase is…

just ramping up its activity. So testosterone is being depleted ⁓ and there’s too much estrogen conversion in that specific pathway. That’s just something that I’ve just observed. And women are getting compounded like teeny tiny amounts of testosterone and it’s like increasing their strength, increasing their libido, bettering their mood, et cetera, et cetera. So this is another reason why I like.

like the Dutch test and in-depth hormone testing, because we can look at all this. ⁓ I don’t know, what do you think about that? Do you look at testosterone?

Dr. Ginger Garner PT, DPT (37:14)

I think that,

yeah, I think that’s brilliant. I don’t think that it’s addressed enough. I think that practitioners are, and here’s what I see sadly in the United States, frequently. And this is even in women without endometriosis. So that means the average woman, perimenopausal woman, will roll in off the street and go, ⁓ my, I feel horrible, know. I don’t have any libido. Everything is like going sideways. Vaginal tissue health is also terrible.

Kimberly Kushner (37:38)

Yeah.

Dr. Ginger Garner PT, DPT (37:44)

And I’ve heard too many practitioners

go, ⁓ we need to go to psych for that because you have to be formally diagnosed with, mm-hmm, yeah, with a psych disorder of libido and then they will actually give you a limited amount of testosterone for a limited amount of time.

Kimberly Kushner (37:50)

Yeah.

⁓ wow.

my gosh, that’s such a roundabout way of getting help.

Dr. Ginger Garner PT, DPT (38:12)

It is, and these women are like going around their elbow to get to their thumb. They don’t want to go to psych, and then some of them are like, I can’t even deal with that. I don’t have a psych issue, you know? ⁓ So they’re being mislabeled with a psych issue in order to access testosterone.

Kimberly Kushner (38:21)

No, exactly.

that’s sad. That’s hard.

Yeah. Yeah.

Dr. Ginger Garner PT, DPT (38:33)

Yeah, but I would completely agree with you

on that aspect because with lesions creating an endometriosis, with lesions creating the rogue estrogen and probably struggling with opportunistic bacteria to begin with, higher levels of beta-glucuronidase that have not been inhibited and no one’s paying attention to it, and maybe they have other issues that are causing an uptick in…

know, aromatase activity, and none of that’s being regulated, I can totally see how that testosterone shift is happening for these women. The struggle is then how to get them help. Here’s the other thing that I have seen happen. I’m really curious about what you’re seeing in your labs is that…

Kimberly Kushner (39:09)

Yeah. Yeah.

Dr. Ginger Garner PT, DPT (39:22)

some women aren’t, even when they can access it, let’s just say they have been fortunate enough to access it and I’m working, I think everyone builds their team, the practitioners they can trust and know that they will ⁓ be able to prescribe testosterone for them, is that after six, eight weeks, they’re not seeing a change in testosterone levels from creams or gels. Have you seen that?

Kimberly Kushner (39:47)

I have been seeing people using troches and it’s working. Interestingly. So yeah, not cream, not gel, getting it compounded in a troche has been good.

Dr. Ginger Garner PT, DPT (39:53)

Yeah. Yeah.

Yeah, I have seen the same. I’ve gotten some ⁓ active online feedback from some pretty powerful Instagram influencers. Yeah, that has been negative ⁓ about me questioning. I was questioning, are you seeing patients who aren’t absorbing gels or creams? And they’re basically saying, no, I’ve never seen that. But when I talk to functional medicine providers, naturopaths, et cetera,

Kimberly Kushner (40:10)

⁓ very cool.

No.

Yeah.

Dr. Ginger Garner PT, DPT (40:31)

They’re like, yeah, I see this all the time. So it makes

Kimberly Kushner (40:31)

Yeah.

Dr. Ginger Garner PT, DPT (40:34)

me think that people aren’t measuring or following up with testosterone levels. They’re just giving them testosterone and not checking to see if they’re absorbing it.

Kimberly Kushner (40:43)

Yeah, maybe. I mean, that wouldn’t surprise me, unfortunately. ⁓ Yeah, and that’s the other thing is from a functional perspective or naturopathic perspective, if that is what the patient is getting, we absolutely need to make sure we are… ⁓ Look, you can take like, it’s not my area of expertise, but you can take aromatase inhibitors. I use herbs and nutrients to help. ⁓

Dr. Ginger Garner PT, DPT (40:48)

Yeah.

With that, yeah.

Kimberly Kushner (41:13)

inhibit

aromatase though, because you don’t want them to have excess testosterone to estrogen conversion, essentially.

Dr. Ginger Garner PT, DPT (41:21)

Mm-hmm. Yeah.

Kimberly Kushner (41:23)

Yeah.

And then a lot of dietary and lifestyle factors contribute to excess aromatization as well. One of them being like insulin resistance, excess inflammation, ⁓ standard Western diet, ultra processed food, excess omega-6, not enough omega-3. Those are just a few off the top of my head, but yeah. So it really does take a holistic approach to try and shift this, even if you are getting compounded hormones.

Dr. Ginger Garner PT, DPT (41:33)

Yes.

Mm-hmm.

Mm-hmm.

very well said. think that contained in that is a very powerful message of hope because again, too often, it’s hard to identify it because mainstream medicine is not thinking about things holistically from a whole person perspective. It often just jumps to pharmaceuticals, big pharma as we call it often, big pharma surgery. ⁓

quick fixes with little to no follow up. Here, take an SSRI. Here, here’s some testosterone, but they never follow up on it. They don’t measure it. They don’t look at levels. And they’re like, just go with how you feel. And I think that the message of hope is ⁓ there are practitioners who are measuring this specifically. There are practitioners who are tracking these things. There are practitioners who ⁓ are using

lifestyle changes, who are using plant-based medicine, who are using very holistic natural options that do work for controlling things like levels of beta-glucuronidase or aromatase inhibition or hormone health, just generally supporting healthy hormones across the lifespan so that someone doesn’t have to say, I don’t feel like myself sexually anymore, right?

Kimberly Kushner (43:16)

Yeah. Yeah.

Dr. Ginger Garner PT, DPT (43:18)

and have a practitioner jump to, not just jump to a pharmaceutical med or dismissal, to say, well, let’s look at all of these other holistic things that go into it. ⁓ And so helping patients make sense of that is like why I was so excited about this conversation or am excited about having this conversation because what you’re doing is helping patients make sense of that in a very holistic way.

Kimberly Kushner (43:30)

Yes.

Dr. Ginger Garner PT, DPT (43:44)

whether it’s endometriosis or perimenopause or HEDS, but then let’s just pause for a moment of silence for all the women who are going through all of those things at the same time.

Kimberly Kushner (43:54)

Yes,

yes, yes, it can be very chaotic. as we know, perimenopause brings about chaos, typically brings about chaos, but in the person with all of these things, estrogen is a roller coaster. doesn’t, this is why bloods are like really ambiguous because it’s literally just a snapshot. It may say everything looks absolutely fine and perfect and you’re good to go.

but we know it’s fluctuating and we know that progesterone starts to take a dive. know that post ovulation, when you release that egg, the little organ that forms your corpus luteum is not producing robust amounts of progesterone like it used to. So therefore you’re having these roller coaster amounts of estrogen that goes unopposed by the progesterone. And then it triggers your mast cells and it worsens your MCAS symptoms and it worsens your…

periods and your endo symptoms. And then your connective tissue issues can also flare because mast cells and ⁓ lax connective tissue are triggering off each other as well. So it really does take a unique individualized holistic approach to pinpoint what are the biggest things right now. Is it your

period pain? Is it your mood? Is it your insomnia? Is it your MCAS symptoms that are flaring? You know, every ovulation. ⁓ What is it? And really target and pinpoint that and move, find the things that are going to move the needle the most. And yeah.

Dr. Ginger Garner PT, DPT (45:33)

Yeah,

that’s very, I guess that really leads us to a practical place, which is hopeful for patients because ultimately at the end of the day, you’re just trying to help patients make sense of what’s driving what.

Kimberly Kushner (45:38)

Yeah. Yeah.

Yeah, yeah. So even though estrogen is still yo-yoing and going through this roller coaster, you still want to focus on estrogen detoxification. I get asked that all the time. Even if my estrogen is going low, yes, absolutely, because it is still yo-yoing. You want to support with progesterone ⁓ and you want to support the phase one, phase two, and phase three of estrogen detoxification. And if constipation is an issue for you, then you need to do all the things to…

help with that and if you need to take that Cal Dglucurate in the meantime, you take that. And if you need to be on mast cell stabilizers, whether they be pharmaceuticals or herbals, like you be on that and your H1, H2 blockers too if you need ⁓ all your physical therapy, all your nervous system support. It’s not easy, it’s a full on thing. Like it is really full on, it’s a lot.

Dr. Ginger Garner PT, DPT (46:18)

manage it.

Mm-hmm.

It’s a full contact sport.

Kimberly Kushner (46:47)

Yeah. And your

adrenals, that’s a whole other thing because your adrenals make your obviously your and your DHEA. ⁓ And if you are mean stress, like we can never we can never overlook the effects of stress on our entire well-being. Like, I know that’s so cliche, but it’s so true.

Dr. Ginger Garner PT, DPT (46:51)

Yes.

It is true. I those two S’s, sleep and stress, because for adrenals to be supported, well, we’ve got to have good circadian rhythm. And so honestly, it does circle back. That’s why it’s so empowering to think that you can, through a very natural, organic, holistic way, begin to manage some of these things that’s not expensive to manage. It doesn’t take anything fancy to do it when you’re trying to normalize, say, stress management and sleep cycles, for example.

Kimberly Kushner (47:18)

So,

Yeah. Circadian

rhythms. Yeah, absolutely. People, sometimes we go down the path of like, it’s, it is comp, I’m not saying it’s not complicated, but there are free things that you can do to help regulate your circadian rhythm. Absolutely. Breathing and getting outside and putting your feet in, in the dirt are like some of my three favorite things. Yeah.

Dr. Ginger Garner PT, DPT (47:52)

Yeah. Yeah. Yeah.

Favorite. Yeah. Yeah, I think we

have a very, very, very similar shared background in terms of the health struggles that we have experienced with all of the different things that endometriosis carries with it. Because more often than not, if you have endo, you have those other things in the bucket that you wish you didn’t have. And so I think a practical question that would really help

Kimberly Kushner (48:21)

Yes.

Dr. Ginger Garner PT, DPT (48:27)

women, whether or not you have endo, especially if you do, because it’s going to be way more complicated, is that what are some of the… I guess if we could drill it down, the first three steps someone can take if they’re dealing with bloating and hormone symptoms, feeling overwhelmed, right? What are some of the first things that you would say, okay, well, let’s look at these three things first?

Kimberly Kushner (48:34)

What

Are you pooping regularly? That’s a big one. Am I on the right track here? Poop, sleep, and diet usually. Those are three of the big things. Stress. You can’t really separate sleep and stress though. Are you sleeping? Are you pooping? And what are you eating? Those are three big things. What about you? What would you say?

Dr. Ginger Garner PT, DPT (49:06)

Yeah.

That’s true. ⁓

Yeah, because ⁓

gosh, I think that ⁓ the diet scoops up so many things at one time, like fiber and hydration and protein and blood sugar stability and that type of thing and nutrition.

Kimberly Kushner (49:31)

Yeah.

Yeah, absolutely. And I love that.

I love going to the nitty gritty of that. That’s why I’m like, ⁓ yeah, that’s all of that.

Dr. Ginger Garner PT, DPT (49:44)

Yeah,

yeah, I’ve found some wild things, you know, when I’m using CGMs with patients that I’m like, ⁓ goodness, let’s tackle this, you know, from a lifestyle medicine perspective. I think bowel bladder, I always want to know how that’s going because, know, the number one symptom outside of reproductive organs that people may experience are going to be bowel symptoms with endo. That’s the number one place for endo to be after, you know, the obvious places. So bowel bladder,

Kimberly Kushner (49:49)

yes.

Yes. Yes.

Yes. Yes. Yep. Yep.

Dr. Ginger Garner PT, DPT (50:14)

nutrition, and I think the whole nervous system regulation. So back to the two S’s again, sleep, so circadian rhythm, and street, sleep, I mean, and stress, meaning nervous, yeah, nervous system regulation, what’s happening with the vagus, you know, et cetera. ⁓ Yeah, I think we’re tracking on those three steps for taking control because if you feel like you have a sense of control about, you know, your healthcare and your healthcare decisions,

Kimberly Kushner (50:19)

Stress and sleep. Yeah.

Yeah.

Dr. Ginger Garner PT, DPT (50:45)

That makes you believe that you can, that your self-efficacy just increases exponentially.

Kimberly Kushner (50:48)

Yeah.

Yeah, and in saying that, I understand that this, like many people traveling down this road have been on this road for a very long time and may feel defeated and feel an inability to advocate for themselves. it’s, and yeah, it’s so hard, but there is certainly…

It’s hard to take autonomy back into your health journey when you have felt so unheard and dismissed for so long. And it’s taken so long for a diagnosis or multiple diagnoses.

Dr. Ginger Garner PT, DPT (51:33)

And I think that when the system

has generally dismissed endometriosis and miscategorized it as a reproductive organ disease only and that kind of thing that you’re so used to being gas lit that when a person walks into an office and they have these symptoms we’ve been talking about related to GI issues and otherwise, they’re already bracing for negative impact.

Kimberly Kushner (51:43)

illness.

Exactly. You go into an appointment on the defense, essentially. I mean, I feel it all the time. It’s like you have to present your case. It’s hard. I hope whoever’s listening has gotten some gold out of this and if not practical tools, then some…

Dr. Ginger Garner PT, DPT (52:10)

Yeah, and it’s exactly the… Go ahead, go ahead.

Kimberly Kushner (52:24)

self-empowerment to feel like they can continue advocating for themselves.

Dr. Ginger Garner PT, DPT (52:30)

Yeah, absolutely. I think one of the things that might be helpful, because we’ve both thrown labs out there that can be critical. So again, if you’re feeling that bloating, fatigue, you’ve identified hormone imbalance like estrogen excess symptoms and low libido, sexual health problems, because as I remind my listeners in every single ⁓ set, know,

Kimberly Kushner (52:38)

Mm.

Yeah.

Dr. Ginger Garner PT, DPT (52:58)

podcast this season ⁓ or episode is sexual health is a part of your base needs, your Maslow’s hierarchy of needs, whatever that is defined, however that’s defined for you. So if you’re feeling these things, we’ve thrown out a lot of labs and assessments that we have found to be helpful. Can you just do like a high level overview of those things, some of the things, some of the labs that you are ⁓ using and or are reviewing on a regular basis to determine

Kimberly Kushner (53:18)

You

Dr. Ginger Garner PT, DPT (53:26)

referral sources or how you’re going to intervene.

Kimberly Kushner (53:29)

Yeah, so the Dutch complete says so much. It shows us stress, shows us progesterone, shows us estrogens, shows us estrogen metabolites, it shows us androgens, it shows us testosterone. So that kind of encompasses a lot, ⁓ but you could also do, yeah, exactly, the stress side of things. Yeah, DHEA, ⁓ how you’re clearing cortisol. ⁓

Dr. Ginger Garner PT, DPT (53:47)

And cortisol.

Yeah. Yeah.

Kimberly Kushner (53:56)

cortisone to cortisol conversion, all of that stuff. ⁓ And then it also shows us some like oxidative stress markers, B12, ⁓ melatonin, all of that. I think it’s really, but you get a lot of bang for your buck ⁓ rather than repeatedly going back to your primary care and requesting bloods at different times of your cycle and this, that and whatnot. I love the Dutch complete. Otherwise you can.

You can always start with like a day two or day three blood draw to look at what estrogen is doing. ⁓ Obviously you wouldn’t do progesterone early on. You would do progesterone, you want to look at it around a week after ovulation. ⁓ But I can also put a list of like what hormones to check when if you can’t get a Dutch test.

⁓ But for things like, for example, cortisol, you want to make sure you do that first thing in the morning. ⁓ And we didn’t even touch on thyroid function, but low thyroid function can absolutely affect your libido. And, you know, your TSH T3, T4, reverse T3, anti-thyroid peroxidase, anti-thyroglobulin, which are your autoimmune markers. Sometimes you may not have full blown hypothyroidism, but

Dr. Ginger Garner PT, DPT (55:00)

I know.

Kimberly Kushner (55:18)

you might have subclinical and those numbers aren’t totally out of range either. So you need to kind of like look at the numbers and look at your symptoms and take your history. so yeah, absolutely. Thyroid as well. You can do that any time of your cycle, but if you want, I can just put a list and write all these down for people.

Dr. Ginger Garner PT, DPT (55:38)

That would be wonderful ⁓ because it’s a point of empowerment when someone comes in and has these symptoms to be able to say these things do matter. And it also helps them choose providers too. If they’re completely dismissed, that’s a very large red flag that they’re not with the right provider yet and that they are able to go out and find that person that they need. Yeah.

Kimberly Kushner (56:04)

Yeah, absolutely. you can

have a look at the Bloods, but you can always find a provider that offers Dutch testing as well. think they may have a list on their website or a search or practitioner search or something. I’m not 100 % sure. But yeah, I think that Bloods and urine serve different purposes.

Obviously, if you want to do like bloods with nutrients as well, because, you know, low iron, low B12, low folate, low vitamin D, that can all affect mood and have a flow on effect on your libido too.

Dr. Ginger Garner PT, DPT (56:47)

Here’s one giant question, you know, ⁓ because in talking about these labs with patients, ⁓ looking at all the labs that you had listed, plus I think higher level testing, then we’ll look at GI ⁓ tests, stool testing, if it gets to that point. But here’s one that I see all the time. So I would love to get your feedback on it before we kind of shore things up.

Low ferritin. I see patients. I know this is going to like create a whole conversation. We’re going to have to have a part three at some point. I think at least three patients that I had last week, I said, okay, let’s look at your labs, bring those in. They’re like, yeah, they said my labs are fine. And either they only measured hemoglobin or when they measured ferritin, and I am not kidding, their levels were 15, 17.

Kimberly Kushner (57:13)

⁓ yeah. Yeah, all the time.

Yeah.

Yeah, very deficient.

Dr. Ginger Garner PT, DPT (57:41)

11 and they’re being told, this normal, and they can’t even get out of bed. They’re so fatigued.

Kimberly Kushner (57:41)

yeah, very. You’re fine. Yeah, no, you’re not. Yeah, so you can have iron deficiency. So ferritin is like a storage form of iron. You want to look at it with.

your serum iron transferrin saturation, et cetera, because you kind of have to look at the whole picture, but just to, for the sake of today, you can have low ferritin and normal hemoglobin be considered non iron deficiency anemic. So you are iron deficient, but not anemic and be sent off on your way and be like, you’re fine. But if your hemoglobin does

tank and you fall into the category of anemia, then you’re considered iron deficiency anemic. And then maybe they may consider you for an iron infusion. Now in some, it depends on the patient, in someone with ferritin levels below 20, ⁓ and they have symptoms like heavy bleeding, endometriosis symptoms, adenomyosis symptoms, you want to, I would love for them to get an IV iron infusion if

they can. If not, obviously you have to supplement orally and see how they go. But you’re constantly chasing your tail and low ferritin will…

Worsen your heavy painful bleeds as well. So it’s like this vicious cycle. I like it over 60 closer to a hundred The other thing we need to be mindful of is ferritin is an acute phase reactant and what that means is it can temporarily elevate high and you may be like, I’ve got high normal iron. ⁓ It can behave that way in the presence of inflammation infection, etc. So you want to

If ferritin comes up high and it doesn’t fit the symptom picture, you obviously want to rule out hemochromatosis and iron overload and talk about family history and things like that. But if it doesn’t match the picture, you want to retest ferritin at a time when they’re not sick, inflamed, ⁓ et cetera, just to get a proper baseline. And if it does drop back down, it means it was elevated as it was reacting to something.

Dr. Ginger Garner PT, DPT (1:00:02)

Yeah, I think that we need more awareness around these subclinical situations where patients are sent away with low ferritin or thyroid levels that don’t look good and they’re still, yes, all these subclinical diagnoses, they’re told they’re fine, but they’re not functional. They’re not getting up and going every day. They’re exhausted.

Kimberly Kushner (1:00:09)

Yes.

Subclinical, Yeah. No,

absolutely. So someone, I mean, if you have ferritin below 20 and you’re feeling absolutely terrible, also check your B12, because if you have low iron and it’s compounded by low B12, that’s going to make you feel even worse. ⁓ If you can’t get an IV iron infusion,

You may want to explore iron injections as well as oral iron. You just need to kind of catch up really quickly. Sometimes that IV just gives you that boost and then you can maintain it orally so much easier, especially if you’re still bleeding. It’s hard when you’re bleeding.

Dr. Ginger Garner PT, DPT (1:01:03)

Have you seen?

It is, it very much is. You can have this persistent subclinical anemia or just full blown anemia that’s being overlooked because I’ve seen that a lot. I’m wondering if you’ve seen with MCAS or histamine issues in general, ⁓ any negative reactions to infusions or injections? I’ve seen that in a few patients.

Kimberly Kushner (1:01:13)

Mm-hmm.

yeah, yeah, yeah, yeah,

yeah, yeah. I always recommend the iron infusion. So normally they give it in like a thousand milligram vial. You can ask it for like half it, 500 or even 250. The only thing is you kind of have to like throw it away and waste it. That’s the only annoying thing. You pay for the whole bottle. Depends what they stock. This is what I’ve done in the past. Just do it in quarters. ⁓ And you can also do it slower.

So usually when they set up the pump, so this is more like nursing logistics, when they set up the pump, usually it’s just gravity fed through your line. You can, ⁓ if the facility allows for it, you can put it through the pump and set a lower infusion rate and get IV saline afterwards ⁓ as well. But of course, like they’re watching for signs and symptoms of anaphylaxis straight away. You just stop it.

Dr. Ginger Garner PT, DPT (1:02:12)

Okay.

Kimberly Kushner (1:02:17)

The only big thing you need to be mindful of is ⁓ hypophosphatemia. So it drops your phosphate levels, but you wouldn’t know that until like the day and days following. But it’s an emergency situation. You’d be extremely weak, have cardiac symptoms, et cetera, that would require an emergency visit. They’d measure your phosphate. ⁓ IV iron can drop your phosphate a lot. ⁓ But I don’t see that much.

mostly see like I get a little bit tachycardic and a little flushed. Some people do take a ⁓ like a H1 blocker like a loratadine which is like clarotin something like that ⁓ as a pre-med but in non-MCAS people it’s typically tolerated really well. I never reacted to the injections just the infusion but I think that’s because it’s a larger dose as well.

Dr. Ginger Garner PT, DPT (1:03:14)

⁓ Very, very good ⁓

observations on that. ⁓ Because I do see it enough that it’s become concerning. Yeah, in that way.

Kimberly Kushner (1:03:24)

Yeah, they’re probably getting too

much. mean, maybe too much and too fast. It’s always like with MCAS, it’s like the slower, the lower, the better I find. ⁓ And some people, I don’t know, I love like flushing with saline. So if the facility allows for like a bag of fluid after that could be a good idea. Yeah. Yeah. It’s tricky. It’s tricky. Yeah.

Dr. Ginger Garner PT, DPT (1:03:28)

Hmm.

Then go, yeah, that would be ideal. Yeah, since electrolytes are so issue, it’s such an issue anyway. Yeah.

Kimberly Kushner (1:03:53)

It will, it will. Yeah.

Dr. Ginger Garner PT, DPT (1:03:54)

All right, so this has been so informative and we’ve talked a lot of nerdy science. ⁓ So if you have any questions, do reach out. We answer all those questions that come around. I would ask one more and that’s like, what’s an empowering message you’d leave with our listeners?

Kimberly Kushner (1:04:00)

Thank

Yes.

Dr. Ginger Garner PT, DPT (1:04:15)

who may feel disconnected from her body or desire, confidence, or just feeling really frustrated about the bloating, hormone, sexual health connection.

Kimberly Kushner (1:04:24)

Yeah. Firstly,

firstly know that you’re not alone. I know that these conditions really isolate people and it causes you to isolate yourself and spiral. ⁓ And if that’s you know that you’re not alone. There is hope. There are resources out there. ⁓ You know, I understand that the journey can be very convoluted for many people and ⁓ not everyone.

And I completely understand that not everyone is in a position where they can invest into all the things and all the modalities. So, ⁓ I mean, I love that we’re doing this. You know, there’s so much free information on the internet now. So gather your resources and really try and prioritize ⁓ what would be the biggest needle movers for you. ⁓ And then pursue that, do your research and be your own best advocate because we just have to not give up, really. You need to find the right people.

and advocate as best as you can for yourself. There is no easy way around it when we’re dealing with complex conditions that we still don’t have answers for. mean, everyone is still trying to figure out endo, you know?

Dr. Ginger Garner PT, DPT (1:05:27)

Yes.

And I think the key point of this is that, well, first, mean, thank you so much for coming back on, helping connect these dots because they’re not separate problems. They’re treated as separate problems, which make patients feel like, I’m just a hypochondriac. I’m just hypervigilant. I just worry too much about everything. No, they’re like really interconnected. And all those symptoms are information for your

body. It’s not that you’re broken or aging or anything. It’s just that you need someone to look at the whole picture.

Kimberly Kushner (1:06:10)

Yes. Yes.

Yes, yes. it, yeah, and I mean, find the best people in the areas that you need help with, if possible. There is so much that’s accessible virtually now. I highly recommend just reaching out and, you know, people who are genuinely passionate about working in this space are happy to answer a few questions to figure out if you’re the right fit or not. You know, because I understand that there’s often still

Dr. Ginger Garner PT, DPT (1:06:41)

Definitely.

Kimberly Kushner (1:06:43)

Is this me? Is this the right thing for me? Would seeing a naturopath be the best first step for me? And I’m like, reach out, let’s chat. I will let you know if I think we’re a good fit. And I’m more than happy to do that. So, yeah.

Dr. Ginger Garner PT, DPT (1:07:02)

And that brings me to my last point, which is, where can people find you? Because there is so much available via telehealth and you identified such a good green flag that people who are experts in the space are more than happy to answer those few questions and say, hey, this could be a good fit, or I think B could be a good fit or C could be a good fit. So would you let everybody know Kimberly where they can find you?

Kimberly Kushner (1:07:22)

Yeah.

Yeah, absolutely. So I’m pretty active on socials these days. You can find me at Endo Naturopath or at www.endonaturopath.com.

Dr. Ginger Garner PT, DPT (1:07:39)

Thank you so much for joining us again for a second time. Kimberly, I can’t tell you how beneficial this has been. We’ve dispelled lots of myths, connected lots of dots, so big gratitude.

Kimberly Kushner (1:07:40)

Yeah. Thank you. Yeah, thank you so much. Thank you so much. It’s always a pleasure to virtually hang out with you, Ginger. Thank you.