Dr. Mark Holthouse joins Dr. Robert Rountree for a two-part discussion on hormone health. In part one, discover the different concepts behind promoting optimal hormone health and correcting imbalances.
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Dr. Robert Rountree:
This is the Thorne podcast, the show that navigates the complex world of wellness and explores the latest science behind diet, supplements, and lifestyle approaches to good health.
Dr. Robert Rountree:
I'm Dr. Robert Roundtree, Chief Medical Advisor at Thorne, and functional medicine doctor. As a reminder, the recommendations made in this podcast are the recommendations of the individuals who express them and not the recommendations of Thorne. Statements in this podcast have not been evaluated by the Food and Drug Administration. Any products mentioned are not intended to diagnose, treat, cure, or prevent any disease.
Dr. Robert Rountree:
Hi, everybody. Welcome back to the Thorne podcast. Joining me this week, we have a wonderful guest, Dr. Mark Holthouse. He's a physician who's certified in both functional medicine and family medicine. He specializes in men's health and also women's health, he tells me, so hormonal health in general, cardio metabolic disease prevention, which he's taught at Loma Linda University, cognitive illness, intestinal disorders, et cetera.
Dr. Robert Rountree:
He's been teaching for the Institute of Functional Medicine since 2014, and I've heard great feedback about his role as a presenter there. So I'm really excited that he's here to share some of his insights with us. How are things going for you, Mark? Can you tell us about your practice, where you are? You've relocated. What's that like for you, and how are you doing in general?
Dr. Mark Holthouse:
Oh, it's a great honor to be here with you, Bob. Every time I see your face, I think of NF-κB. I'm so sorry, but it's a little bit of a PTSD experience for those of us who have gone through the certification, but the dark sunglasses and the limousine analogy will be immortalized long after you are gone from this rock.
Dr. Mark Holthouse:
We are coming to you live today from Boise, Idaho. I've been a transplant here after a native Californian. I've been here about 18 months and took a job opportunity where I moved from a concierge-hybrid model of functional medicine in Cali, where I'd been for 32 years doing family medicine and the last 15 of that integrative functional. And we came out here really because of the amazing outdoor experience that Idaho affords, but also the opportunity to be back into an insurance model, however long this will last. We'll see.
Dr. Mark Holthouse:
We've got just a tremendous demand. I've never seen anything like this. We can't hire physicians and clinicians fast enough to meet the need out here in the Treasure Valley. We have started with six people 18 months ago seeing clients and about 20 staff overall and two locations, Boise and Meridian, which is nearby, to fast forward 18 months. We're now at a hundred employees, over 20 practitioners and four locations in Idaho.
Dr. Robert Rountree:
Holy cow.
Dr. Mark Holthouse:
So the growth has been phenomenal. It's always interesting to me how you throw out the we take your insurance tagline. And even though we all know we have high deductible plans and we're out of pocket the first part of the year if not the whole year, it does seem to be a difference.
Dr. Mark Holthouse:
It was weighing heavy on my heart, going to those Sunday afternoon Costco trips and being assaulted by former patients saying, "Oh, Dr. Holthouse, we miss you. We wish we could afford you." Concierge membership thing, just got to be too much.
Dr. Robert Rountree:
Yeah.
Dr. Mark Holthouse:
And you're kind of looking at your shoelaces saying, well, okay. So anyway, this is kind of a consummation of trying on a different model and wow, it's great. The people out here in South-Central Idaho have really embraced root cause medicine.
Dr. Robert Rountree:
Oh, great. Right, well, yeah, it sounds like things are really booming.
Dr. Mark Holthouse:
They are, I mean, the growth pains have been at... I'm their Med Director, so I'm seeing patients two, three days a week and running around trying to act like I know what I'm doing the rest of the week to get process and policy and standards of care in place for this motley crew with over 20 of practitioners, you can imagine. Most of them, four of us are MDs, most of the rest are all advanced practitioners. So it's fun, having a blast.
Dr. Robert Rountree:
I guess you have to fake it until you make it, right?
Dr. Mark Holthouse:
Yes.
Dr. Robert Rountree:
Just pretend like you know what you're doing and-
Dr. Mark Holthouse:
Yeah, I told the owners that after I'd been here about 18 months, I said, "I tricked you guys in hiring me." I've had all this 30 years of owner operator experience, but really being a Medical Director of three or four people owning a building is a lot different than what you guys are having me do. But it's been a hoot. I'm enjoy it.
Dr. Robert Rountree:
Now what percentage of your practice on a day-to-day basis would you say is just straight family medicine, typical lumps and bumps, colds, flus, things like that? And what percentage is what we call functional medicine or systems biology medicine where you really get into the root causes as mentioned earlier?
Dr. Mark Holthouse:
That's a great question because one of the reasons they hired me was I have this hybrid pedigree, right? Similar to yourself, family practice with the other board. You have integrative med and then certified and functional.
Dr. Mark Holthouse:
And we have the offering of primary care medicine so as to avoid putting patients in that consummate tug of war between a western primary care telling them what they should do for their hypertension, and then coming here and us trying to unravel everything and recommend it another way.
Dr. Mark Holthouse:
And so having all of that under one roof has been an incredible value add, I think, for patients. It's also an incredible drag on resources when you enter family practice, when sitting on the phone for an hour and a half for prior auths and all that goes along with offering those.
Dr. Robert Rountree:
I know all about that.
Dr. Mark Holthouse:
Preaching to the choir, I'm sure. So we've come up with an idea where we've got folks in pods, similar to what some of the other models I've seen have, Virginia Mason kind of a deal, where we've got MAs, we've got schedulers and practitioners all in these groups. And some of the groups are, all of us are doing basic functional medicine.
Dr. Mark Holthouse:
Some of the groups are doing primary care and healthcare maintenance, and other groups are doing full on biotoxin illness. Other groups are really doing deep dives into mold and things like this and environmental issues.
Dr. Mark Holthouse:
And then we've got dedicated practitioners that we simply hire to do nothing but physicals and acutes and walk-ins, and keep the healthcare maintenance dashboard on the MDHQ or whatever we're using now, health record system, up to date.
Dr. Mark Holthouse:
We advertise that we're going to of do both, and a lot of the folks that gravitate towards functional medicine, they just as soon jettison the mammogram and colonoscopy secretarial work in their rear view mirror. So we give the practitioners the option of doing both, just being a consultant in functional realm or exclusive on the primary care and delegating it that way.
Dr. Robert Rountree:
So this is really true, integrative medicine.
Dr. Mark Holthouse:
It is.
Dr. Robert Rountree:
Which is the spec you practice. It sounds a little weird, but you practice on the spectrum.
Dr. Mark Holthouse:
We do. We do. We have this filter with our new patient process that says, "Hey guys, there's plenty of docs in the valley that will just play whackamole and name it, blame it and tame it med. We are going to ask you to do some significant soul searching, dietary manipulations, therapeutic lifestyle stuff. If you're willing, great, we're probably a good match. If not, thanks for playing, but there's plenty of other folks that that can do what you're looking for."
Dr. Robert Rountree:
Now since you're the Medical Director, I guess you have the final say over whether a certain intervention, like a nutritional intervention would be considered cool or not. So if somebody had hypertension and they didn't want to go straight to drugs, and the doc wanted to put him on hibiscus tea, you're not going to say, "Oh my God, what's he doing there?"
Dr. Mark Holthouse:
Exactly, exactly. We're kind of trying to model what Cleveland did, Cleveland Clinic, with their department. And the biggest issue we have is long wait times, which is what happened right away when they opened that clinic. And so we modeled it, they called it Functioning for Life, I think, where they had a functional med light or foundational choice.
Dr. Mark Holthouse:
I think it was originally kind of a mandate, where it was a 10 week, 40 hour course, they had to do that to get to the docs.
Dr. Mark Holthouse:
We tried that, and it didn't get received real well. So now it's an option of waiting for three months to get in for your initial intake or getting on the ball with your lifestyle stuff with the coaches and talking about sleep hygiene and stress and nutrition before, so that we can kind of hit the ground running once you're in with your doc.
Dr. Robert Rountree:
Do you find that your average person off the street that comes into your practice is interested in alternatives in general? I mentioned hypertension is one example. Do you have a lot of people that say, "Doc, I hear that I've got high blood pressure, just fix me," or do you have people who are looking for different strategies that are say less toxic?
Dr. Mark Holthouse:
Yes and yes. We have the group that says to our Patient Experience Navigators, our PENs, we call them, "Hey, I saw your name in the Blue Cross listing, and that's why I'm here." And we try to inform them right off the bat, "Hey, this is what we're all about. Is that still something you're interested in?"
Dr. Mark Holthouse:
So we've got a filtering mechanism right up front so as not to make the job of the nutritionist more of a sales job and less about what they are trained to do. And so it's actually a pretty rigorous screening test.
Dr. Mark Holthouse:
We always say that by the time they fill out the online intake packet, it really is a measure of their commitment. That being said, we get people through that are in both camps. They're here at the encouragement of their significant other half, their arm twisted.
Dr. Robert Rountree:
My wife made me come in.
Dr. Mark Holthouse:
My wife made me come in, and they're all over the map, right? It's like, you can sometimes win them over by logic and explaining the why doctors versus simply having the what. And some of these guys are, in particular, there are also women as well, are very logical, very educated, intelligent people. It's pretty easy to win them over. And then they're always looking at starting with lifestyle before they go right to the drugs.
Dr. Mark Holthouse:
And then there's just the blatant ones. And I actually love them for their honesty who I'm just here for the free food. It's I have no interest in what you've just described, but I really like you, Dr. Holthouse, and I really liked your front receptionist. She was nice. And she smiled to me, and I appreciate that personalized touch, which I wasn't getting at the big corporate experience down the road.
Dr. Mark Holthouse:
And some of those folks, we actually do win them over, and it's all about rapport and their therapeutic readiness to change where they're at. We get a lot of precontemplative folks, and that third category is the expert, right? The ones that come in that have had 11 functional practitioners before you, and their life seems to be on the internet and in forums and doing summits, and frankly, they're really terrifying because they often know a lot more than I do.
Dr. Robert Rountree:
And if they bring in 50 pages of labs.
Dr. Mark Holthouse:
Exactly. So I'm just really open with them and say, "Hey, I'm a mere mortal. There're areas I know very little about. There're areas I know a little bit about, and if I can be of help to you, great. If I can help point us in the right direction to go get more learned on an area and make this happen together, I'm your man." So yeah, we get them all.
Dr. Robert Rountree:
So let's segue from that into the main discussion this week is hormonal health. And I would ask the same kind of questions. Do most people that are say in need of hormonal support or hormonal replacement, are they aware that they need hormonal replacement?
Dr. Robert Rountree:
Now I imagine it's going to be more true for women than men, that women go through menopause, they have hot flashes, and they say, "How about I get some of that estrogen?" Right? But I don't know if it's going to be as true for men.
Dr. Mark Holthouse:
Yeah.
Dr. Robert Rountree:
That it would immediately occur to them that I might need testosterone or DHEA or something like that. So what's your experience around assessing people for hormonal health and resistance to it or eagerness to do something about it? What's the general awareness in your population?
Dr. Mark Holthouse:
Yeah. That's my day to day task right there. And it's very different between the two genders. I mean, we've got females that often come in with an agenda, either regarding their thyroid replacement, often because there're more commonality there with hypothyroidism statistically, and they've read enough or talked to their neighbors or been somewhere where they've been told the TSH is not adequate to assess the function of another gland in and of itself. How do you guys look at the thyroid? It's almost like they're interviewing me. And they do the same thing with BHRT, with Bioidentical Hormone Replacement Therapy. There's kind of like this secret handshake that some of these folks come in with, but there is this expectation-
Dr. Robert Rountree:
They're going for that look in your eyes- [crosstalk 00:14:56]
Dr. Mark Holthouse:
Exactly.
Dr. Robert Rountree:
... to see does she have it?
Dr. Mark Holthouse:
Exactly. And so there's a little bit of this cat and mouse when you're first doing the new intake, figuring out where are they coming from and what is their real agenda motivation? And I find a lot of times with the females that they have a preconceived agenda that from what they've heard, learned, read, hey, I've got these symptoms, I must need X.
Dr. Mark Holthouse:
And so it always leads to this discussion of adrenal and thyroid and sex steroids, and the unfortunate overlap of symptoms that occurs with all three of these things, making it incredibly cloudy at times.
Dr. Mark Holthouse:
And so with guys, yeah, sometimes at the behest of their significant others, they're here to find out if testosterone could be the root cause of their being a grouchy, irritable curmudgeon or their lack of interest, but often they are being educated as to hormones being possibly the etiology more so I find than the gals.
Dr. Mark Holthouse:
My biggest challenge with both groups is to talk them off the ledge of I'm here for the trophy to leave with the prescription and back peddle and say, "Well, okay, I get it. And that would be really easy for me to do. That's a great knee jerk thing to do with this list of symptoms." But I always tell folks I see hormone imbalances as is really the tail being wagged by the dog. It's downstream, including adrenal.
Dr. Mark Holthouse:
We have these folks coming in with these other root cause issues, and I try to get them to see it through my eyes as I could do that for you as you're asking. That would be really easy for me. Let me see if there's something else I need to look at first that's driving your imbalance, such as inflammation, leaky gut, stress, sleep, all of those. And it's fun because you see them. They realize you've just turned the tables on them, but they're like, I'm okay with it.
Dr. Robert Rountree:
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Dr. Robert Rountree:
So what you're really talking about is the difference between silo medicine, right? People that come from farm country, know what I'm talking about.
Dr. Mark Holthouse:
Yes.
Dr. Robert Rountree:
Everything's in its own silo, and that's what the endocrinologists do, or the gynecologist will do is say, "Well, hormones, you're going through menopause. It's all about estrogen. And maybe progesterone and maybe testosterone."
Dr. Robert Rountree:
But you're saying, well, there's other glands involved. There's the whole endocrine system that's involved, and that's really functional medicine is to go hey, it's not just your ovaries.
Dr. Mark Holthouse:
Yeah.
Dr. Robert Rountree:
It's not just your testicles.
Dr. Mark Holthouse:
Yeah.
Dr. Robert Rountree:
Right? You've got this whole other glandular system. You've got your adrenals, your pancreas, your parathyroids, who knows? So that's thinking systemically, and I'm wondering, to a functional medicine practitioner, that's all right up front. That's how we're trained. That's how we think. Do you get pushback from your mainstream colleagues that go, what the heck are you talking about? How could adrenal function affect what's going on in the testicles? They're different parts of the body.
Dr. Mark Holthouse:
All the time. All the time. My goal being new to Idaho is to make as many friends in my allopathic brothers and sisters here in specialty care, especially the areas that I tend to read a lot on, your urological stuff, cardiovascular stuff. So getting a good gastroenterologist, understanding that you're not completely out in left field, so that I can start co-managing. Rheumatology, same thing, as well as the cardiology guys, and urologists.
Dr. Mark Holthouse:
Endocrinology, boy, that's a tough crowd. I have yet to figure out a way to win the hearts of my traditionally trained endocrinologists for the most part. And so they get to see my type 1 diabetics, and that's pretty much it.
Dr. Robert Rountree:
You would think that if you real understand endocrinology, it's all about cell communication.
Dr. Mark Holthouse:
Exactly.
Dr. Robert Rountree:
Right?
Dr. Mark Holthouse:
Exactly.
Dr. Robert Rountree:
It's about how does the whole body communicate with each other? So you would think of all the specialties, endocrinology would be one that appreciates systems biology more than any other specialty. And yet it's in my experience, it's the opposite. If you've got Addison's disease, if you've got adrenal deficiency, then that's what you have.
Dr. Mark Holthouse:
Right.
Dr. Robert Rountree:
Right.
Dr. Mark Holthouse:
Exactly. Yeah, it's just funny. It's an interesting observation that when I've worked with rheumatologists, especially the ones that tend to be a little bit more younger in their experience, it's almost like when you co-manage a few patients, you kind of win them over. And the whole topic that you've given on citrullinated proteins and how the environment can alter self with exchanges of amino acids here and there and these sequences, they realize, wow, this guy is not talking about voodoo medicine. He's actually is talking about biochemistry. And suddenly I'm feeling intimidated within my own sphere of expertise by a family practitioner.
Dr. Mark Holthouse:
And so you're giving them this glimpse that you're serious, and yet you're rolling over and showing your vulnerable family practice self so that they don't get pushed away.
Dr. Mark Holthouse:
And it's just this dance that probably poor nurses in the hospitals and surgical nurses have had to play with these arrogant surgeons their whole career. And so I have a new appreciation for my nursing colleagues. But it's fascinating, I think, and it's an incredible opportunity to work with traditionally trained specialists.
Dr. Mark Holthouse:
One of the things that I really push with the practitioners in the fellowship that we're doing here on training newly licensed practitioners in functional medicine is, hey guys, don't cut off your colleagues. Don't worry. You're not probably going to sell them. Every once in a while you might have somebody come over. You are a parallel universe that is coming up alongside their expertise. We need each other. You want to always come at them promoting how awesome they are, which they do amazing things, but don't back down from a fight either. And don't get emotional. Use references, use data that's often published in their own peer reviewed journals that they haven't had time to read.
Dr. Robert Rountree:
So let's get into maybe a specific. Let's say a guy comes in thinking, well, he's in his fifties. And he said, "I saw this ad for low T, and so maybe that's what I've got is a testosterone deficiency. And I was wondering if you could give me a shot or a cream." So what do you do with somebody like that? Do you do a workup in general with men and women? Do you immediately start testing and determining what their hormone levels are, or do you do more gentle interventions?
Dr. Mark Holthouse:
Great question. I mean, when it's premenopausal females because assessing their hormones, which are usually all over the map, that's certainly not the first thing we're going to check. We will do specific dried urine testing and cycle mapping and things where we do multiple tests throughout the cycle on some of them if we really need information on ovulatory patterns outside of just these commercial kits you can get over the counter.
Dr. Mark Holthouse:
But really with the premenopausal perimenopausal females, we're starting with gut health. So much of this hormone stuff is based on where things are with the gut. In particular, estrogen dominance, which is the majority of what I see in that age demographic coming in with the painful, heavy periods, lots of clots, PMS, a history of endometriosis, and maybe even some ovarian cysts and fibroids.
Dr. Mark Holthouse:
And this is the group that you really try to focus on, not just promoting healthy estrogen metabolism and detox, but you really are trying, I find, to win them over to the points of leverage, I like to call it, that affect hormone imbalance, and particularly with estrogen dominance.
Dr. Mark Holthouse:
The guys are great with their testosterone because they usually come in because of ED, or I'm working out at the gym two hours a day, and I look like a string bean still. What's wrong? And my neighbor who works out half as much is getting all these results. And so there're various reasons it drives the guys in, but it's always-
Dr. Robert Rountree:
Performance, usually performance issues.
Dr. Mark Holthouse:
Usually it's performance. We're so performance driven. So we'll talk about the relationship of their increasing girth and central obesity and insulin resistance with hypogonadism. We talk about the lack of sleep, the stress, and all of these really glaringly obvious things that they often come in with. The guys I'll usually check testosterone with their initial rainbow panel of an initial labs as a routine, especially if they're over 30, 40 years of age.
Dr. Robert Rountree:
They're doing a blood "performance" panel.
Dr. Mark Holthouse:
They are.
Dr. Robert Rountree:
And that what's on the performance panel?
Dr. Mark Holthouse:
Exactly.
Dr. Robert Rountree:
Testosterone.
Dr. Mark Holthouse:
That's right. And it's a great motivator when they see those numbers. On the post-menopausal side with women, we do the same. Often we'll get either a urine or a serum test to begin with, depending on what we need to see if it's metabolites or just the actual hormone levels. And that's a great place as a starting point to see where they are.
Dr. Mark Holthouse:
But so many of them don't really understand that if you're stressed, and there's a saber-tooth cat chasing you across the savanna, your body does one of two things. It's going into survival mode, making cortisol from all of that lovely pregnenolone and cholesterol, or it makes babies. The baby making machinery, or the testosterone making machinery in men and women is turned off when you're stressed out.
Dr. Mark Holthouse:
And that includes chronic pain and not sleeping well and eating inflammatory foods. And when they make these connections, it's like the first time they've ever thought of that or heard of it. So that's the fun part.
Dr. Robert Rountree:
So your job really is to connect dots in people.
Dr. Mark Holthouse:
It is. It's-
Dr. Robert Rountree:
They come in, they go, "I'm really focused. I think I've got a hormone problem." And your job is to say, "Well, there's more to it than you have a deficiency, and we need to correct the deficiency."
Dr. Mark Holthouse:
Yes, exactly. And there are those people who will come in and say, "I'm willing to go this far with you on discovery, but I'm miserable." And you know what? As long as there're no contraindications, I'll often start them on something just to buy. And I always say it this way. I say, "Hey, we're going to do this RX, or we're going to do this direction to buy time, so that you and I can actually keep you from needing this stuff the rest of your natural born life."
Dr. Robert Rountree:
Thanks for listening to our conversation with Dr. Mark Holthouse. To keep this episode from getting too long, we decided to split our discussion into two parts. Tune in next time when Mark and I will dive into some hormone related questions from our listeners.
Dr. Robert Rountree:
Thanks for listening to the Thorne podcast. Make sure to never miss an episode by subscribing to the show on your podcast app of choice. If you've got a health or wellness question you'd like answered, simply follow our Instagram and shoot a message to @thorneresearch.
Dr. Robert Rountree:
You can also learn more about the topics we discussed by visiting thorne.com and checking out the latest news, videos, and stories on Thorne's Take 5 Daily blog. Once again, thanks for tuning in, and don't forget to join us next time for another episode of the Thorne podcast.
