Perimenopause and Women’s Hormones


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Webinar Transcript: Perimenopause 101

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Welcome today we’re going to be talking about perimenopause and trying to make sense of the chaos a little bit so again for those of you who don’t know me I’m Dr Miranda Naylor I’m an osteopathic doctor board certified in family medicine and functional medicine and I specialize in women’s health the reason for that is that when I was in Primary Care in the past and even during my family medicine training I realized that there was a huge lack of proper care for women in medicine you know there were so few tools so few answers to concerns that were particular to women I also love that we go through all these incredible phases and you know a woman in her 20s is not the same as women in her 50s and we treat them there’s so many things we can do differently and treat them differently and to really optimize their health through every phase so that’s really what my passion is and on that same note that’s why I’m talking about perimenopause today because it’s such an important phase in our life that unfortunately doesn’t get a lot of screen time you know not a lot of people really are aware of it or at least to the level that they really should be I think it’s really important that women are aware of it as early as possible honestly so that we can see the signs when it is coming on and know that we can get support if we’re having really Troublesome symptoms so I see patients out of Encinitas California at Solcere and also see patients virtually and before I go even further too I wanted to note please stick around through the end of the presentation for those of you who are here live because they will have a special offer for you so I want to make sure I say that ahead of time to give you a little incentive to stick around so this evening we’ll be talking about how to define perimenopause some common symptoms typical hormone patterns during this time which can help us really make sense of things and different risk factors that come up and the best options for testing so we’ll start with defining perimenopause so the straw criteria were created by the stages of reproductive aging Workshop basically they put together these criteria to help us Define the pre-menopausal phase perimenopause and menopause so the pre-menopausal phase is regular menstrual cycles ranging from 20 uh 22 to 35 days now this is to be said that not every woman has a regular menstrual cycle and might be having short or long periods or something else going on but this is what a normal menstrual cycle should be and then the perimenopause phase is defined as a change in cycle length of at least seven days either longer or shorter in either direction from Baseline for at least two cycles so that would be a woman who if she typically has a typical 28 day cycle and and then suddenly for two cycles she’s having a 20-day cycle then she would be in the perimenopause stage at that point and then menopause is not having a period for at least 12 months this of course you kind of have to deduce later after 12 months you can finally say okay yes I’ve been in menopause for the past year but that’s really the the strict definition of it now I love this picture to show that there are different stages of the transition as well it’s not like we’re in a pre-menopausal stage and then we’re perimenopause and then we’re menopausal it’s really this progression that’s happening so perimenopause is initiated by a decrease in ovarian reserve which are these immature egg cells that have a potential to ovulate in our ovaries in the late reproductive phase Cycles are either regular or starting to become slightly irregular and we can start to have a lower ovarian reserve in our ovaries then in the early menopausal transition this is where we start to have that seven day difference in Cycles either shorter or longer then an elite menopausal transition Cycles are at least 60 days apart meaning this is going to be the woman who starts to have you know three months between periods four months things can get really inconsistent and then the early post-menopausal phase is we’ve had our final menstrual period and then we’re not having any more periods after that so this is a picture of an ovary just to sort of give some context of what a normal ovarian cycle is I feel like it’s helpful to talk about what’s normal before we start talking about what becomes abnormal in the perimenopausal phase so we start here with these primary follicles which are basically like the ovarian reserve these are immature egg cells which have the potential to grow bigger and become an egg cell that can be ovulated so in response to FSH which is from our brain our follicle stimulating hormone these grow and mature and oftentimes several will be maturing at the same time one becomes the dominant mature follicle and that is the one when the signal comes to ovulate that’s the one that ruptures the follicle ruptures the egg is released and then that follicle turns into What’s called the corpus lute and this is what produces progesterone so I feel like that’s really helpful to know because this is the only thing that’s creating progesterone so if we’re not ovulating which starts to happen in perimenopause then we don’t have progesterone and that can come with different symptoms and as we head into perimenopause as this ovarian reserve declines FSH starts to rise in response to that and the analogy I give is that usually FSH just has to whisper at her ovary like apes you know start to grow start to create these larger egg cells let’s ovulate and it just take that’s all it takes when we’re having a lower ovarian reserve and we’re heading into perimenopause all of a sudden it’s like FSH has to scream like hey come on let’s get going let’s do this and that can cause a lot of the symptoms that are coming up as well or make sense of some of the patterns that are happening so this is again a typical pre-menopausal menstrual cycle and you can see here these are the hormones coming from our brain particularly our anterior pituitary that’s telling our ovary giving it the signals of what to do kind of maintaining this this regularity that follicle stimulating hormone that I mentioned is here in green you can see it it comes up a little bit and again usually it’s just that little bit of a whisper to get those egg cells to start maturing goes up a little bit during ovulation and then studies back out luteinizing hormone is generally pretty steady and low and just has this one big spike which is what triggers ovulation estradiol this is on the ovarian level estradiol which is our main estrogen is released by those egg cells that are maturing and so it should have sort of a steady climb throughout the follicular phase which that first half of our cycle and then it drops off during ovulation when it gets that signal from LH and then it goes up a little bit again in it is also produced by the corpus lute so it goes up a little bit again and then drops down before the period progesterone as I mentioned is pretty much flatlined until we ovulate and then when we have that corpus lute that develops then we’re having a nice progesterone and level and that goes until the corpus luteum degenerates about 10 to 14 days after it’s created and the drop in both those progesterone and estrogen are what cause menstruation and that’s when we get a period again knowing these things I it might feel like going back to science class but I feel like it’s important because it can make sense of like oh hey if I’m having mid-cycle spotting hmm maybe I’m having a big drop in estrogen or something like that I mean start to make sense of these things now to head into perimenopause and the menstrual cycle that starts to occur here I love these these diagrams these are in a study showing the estradiol levels and progesterone levels of different women in perimenopause and you can see how erratic things are not only in the timing of the different spikes of the hormones but the different levels there’s so much variation from Woman to Woman and even you know these are different women but when we do look at it even the same woman’s levels it can be completely erratic um and largely at least one one of the main reasons why this is what’s called Loop Cycles or a ludial out of phase Cycles basically because FSH is yelling and we’re having this Fast and Furious response of the follicles they’re maturing at a much faster pace and we can have these more rapid recruit what they call recruitment waves that can start becoming out of sync with our normal cycle so typically what that’s just happening in our follicular phase it’s being suppressed during the rest of our menstrual cycle from our other hormone levels but during the perimenopause period because it’s happening so quickly and FSH isn’t going down the way it normally would and we can start having these rapid recruitment waves and we can start having compounding estrogen levels so again the estrogens are produced by those follicles and if this is happening at several different times we can start start having layering of the estrogen levels so you can see here this picture this dotted line is this out of phase dominant follicle estrogen so basically this is showing that ovulation can happen even during the period and you can start having even high estrogen symptoms at random times or unexpected times like during the period another thing to note is during the perimenopause period we aren’t ovulating as regularly so that can be another Factor too where we can have these big recruitments but we’re not actually ovulating and so we’re not getting again the normal feedback like negative feedback that we would to stop these Loops from happening so to go again into the some of the hormone patterns that are happening here so ovarian reserve starts to decline that’s the first thing that happens and this is just over time our our eggs start to be depleted and that declines and in response anti-melanian hormone declines excuse me got a tickle all right so anti-mullerian hormone is secreted by these follicles it’s used in we’ll often test for it when we’re talking about fertility because it’s used as sort of like an indirect estimate of ovarian reserve of course I’m gonna lose my voice right now um so um what was I just saying so it’s it’s not the best test especially when we’re talking about it for fertility there are a lot of other factors that can lead to an abnormal amh level but in this context yes we do know that as oberian Reserve declines our amh naturally lowers and then eventually gets to a certain point where we know that ovulation is going to be really inconsistent and fertility is really inconsistent then from there as I mentioned follicle stimulating hormone increases and this usually happens about three to four years before the final period to give some context then from there LH or luteinizing hormone Rises about two to three years before the final period estrogen again as I mentioned could remain about the same or it could rise initially before it is lowered in the post-menopausal period and then progesterone slightly declines gradually in the Years prior to the final period And as I noted it is not present at all if we’re not ovulating so that’s where the progesterone levels can become very low overall but also erratic and then I liked this diagram to show kind of more of the long-term scheme of what’s happening with our hormones you can see in the pre-menopausal phase we’re having these nice steady cycles of our hormones and then in the perimenopausal phase things get erratic or estrogen levels become much higher than they normally would and eventually start being depleted progesterone can be low for long periods of time when we’re not ovulating so this can cause a lot of disruption and imbalance foreign and again knowing these hormone patterns I think is so helpful to me you know for what I do and as I’m helping patients I think it really makes sense of of the symptoms they’re having and that’s why I wanted to share it with you as well is like if you are heading into perimenopause and trying to figure out why you’re having symptoms when you’re having them and I think it’s really helpful to have that context to know oh okay these are the symptoms that can go along with higher estrogen or estrogen drops so when does this affect women a study in out of New Zealand showed that about 20 of women at age of 40 were considered to be in the perimenopausal phase and then as I mentioned ovulation becomes inconsistent so about three years before the final period about 70 of Cycles are ovulatory and about two years before the final menstrual period about 50 of Cycles are ovulatory and then in the final year before the last period only about 22.8 percent of Cycles are ovulatory so we start to have more and ovulatory Cycles meaning we haven’t ovulated but we’re having bleeding episodes in this time foreign so some common symptoms of perimenopause some are somewhat non-specific and things like fatigue insomnia very classic irregular cycle length as I mentioned oftentimes they become shorter before becoming longer irregular period consistency so women start having really heavy periods when they’re ovulating and then when they’re not ovulating they might have this you know very light easy period because it isn’t actually an ovulatory period and it’s just sort of a withdrawal also some of the hormones mood changes are very common during this time as well either worsened PMS from those higher estrogens but also depression is very common in the perimenopausal and menopausal phases both vasomotor symptoms are also really common hot flashes night sweats and palpitations as well so diagnosing perimenopause diagnosis is on a clinical basis meaning there’s no one blood test that will tell you that you’re in perimenopause it’s really looking at cycle length looking at the symptoms and putting it all together when we’re looking at symptoms they can be very variable throughout a women’s cycle based on hormone levels and reflection fluctuation so like I mentioned it could be that we’re having high estrogen symptoms could be that we’re having low progesterone symptoms or it could be that we’re having this rapid drop off of estrogen which is causing symptoms most women often aren’t aware of the difference between ovulatory and ovulatory Cycles until they know this you all will be better prepared but most women will say well yeah I had this random period they didn’t have any symptoms it kind of caught me off guard or I’m having these terrible like you know inconsistently having really heavy periods or really light periods and this can be why so it can help make sense of things by knowing okay maybe looking for PMS symptoms when we’ve ovulated like breast tenderness to irritability bloating versus looking for perimenopause symptoms like hot flashes low mood and insomnia and the symptoms of perimenopause can affect each other as well so not surprisingly if you’re having terrible hot flashes at night you’re not going to sleep as well and then the next day you might feel a lot more tired or depressed but also Studies have shown that women who are at greater risk of worsened symptoms in one category will also have worsen symptoms in another category and there are predisposing factors to having worse symptoms and having higher risks so some of the predisposing factors include hormone levels as well as hormone sensitivity so that the difference there would be if you’re predisposed to estrogen dominance for example or if you’re just in a picture of being sensitive to hormones some women have a lot of sensitivity to estrogen levels or progesterone levels previous depression or insomnia which is maybe not surprising if someone already has a hard time sleeping and then they’re hit with perimenopause and they that woman is going to be more likely to have a harder time sleeping in perimenopause high stress is another big factor and of course we can kind of blame stress for a lot of things but it has been shown that it is a compounding Factor for worsened perimenopause symptoms and interestingly phthalate exposure also increases the risk of poor outcomes phthalates are a type of chemical that are found in a lot of conventional products particularly in fragrance so anything that has fragrance even if it says natural fragrance more often than not it’s a phthalate and these are endocrine disrupting chemicals and it has been shown that higher phthalate exposure is associated with you know worsened vasal motor symptoms which are the hot flashes and night sweats and even cardiovascular disease so good thing to note that even our toxin exposures can absolutely play A Part here so tracking Cycles I’d love to see here just to sort of break things up in the chat let me know do you track your Cycles are you familiar with tracking Cycles I’d love to know you know who’s familiar with this if this is new to anyone but I think that Joy says yes awesome love to hear it um so someone says in menopause now but did track awesome it probably helped to know what was going on with your cycle you know it I find it so helpful for a lot of different reasons I mean just women just being able to know their menstrual cycle and then again during this time when we’re having these erratic patterns it can really help make sense of like oh hey it looks like that was an inovulatory cycle no wonder I’m having these you know perimenopausal symptoms versus PMs and as we’re treating things it gives me a lot of information as well to know oh yeah it looked like your temperature didn’t rise for example it looks like it was in ovulatory we can give you different kind of support in that context versus another it’s gonna be really helpful some things to also be aware of so PMS will not occur in auditory Cycles so again that would be like you know all of a sudden I had this really easy period it just caught me by surprise that would likely be an avatory cycle or an auditory bleed and then perimenopus perimenopausal symptoms often arrive during periods of lower estrogen typically that would be a few days before the period through a few days into the period or more typically where we’ll see perimenopausal symptoms and there could also be more consistent uh regular symptoms that are going on that are then worsened in longer periods of amenorrhea or those longer periods without a period so so that can help kind of make sense of things yes and just reading some of the comments so it started with night sweats hot flashes and now not sleeping well and missing periods from month on and off yep you were right there in it well hopefully this will help make sense of things a little bit all right so to go into some health risks that come up during perimenopause and menopause so bone loss this is one that’s maybe not surprising as our estrogens lower we can start having osteopenia or osteoporosis cardiovascular disease and this is actually a really big one that if we address things early as early as possible we can decrease our risk of so you know risk increases as FSH increases meaning that as we’re going through that progester that progression and FSH continues to rise and then we’re having more and more risk until the postmenopausal and phase which it stays fairly consistent women with PCOS may not get as much protection from treatment as for cardiovascular disease meaning another woman might have decreased cardiovascular risk with HRT or hormone replacement but a woman with PCOS might not have quite as much cardiovascular protection from the hormones Alone so it’s good to be aware of so that again we can treat them differently and put them in a different context to really customize things to that woman low thyroid function as well also increases cardiovascular disease particularly a TSH of greater than 2.5 has been shown to increase risk a bit and there are also risks of cognitive changes that go along again with the lower estrogens metabolic syndrome which is characterized by insulin resistance weight gain often elevated blood pressure elevated triglycerides as well as sort of random seeming things like carpal tunnel dry eyes and decreased kidney function and they have been correlated in the literature with perimenopause so I want to break things up again and show a case study here of one of my patients we’ll call her Jessica so she was a 52 year old female who came in to see me because she felt like crap she felt like she had aged 10 years in two years and she wanted to know what the heck was going on she was fatigued she had gained 20 pounds without changing her diet or doing anything differently she had terrible brain fog she couldn’t exercise because it just wiped her out she had terrible mood was feeling really irritable and just down I was having hot flashes as well she had high stress at work she also had a history of endometriosis and fibrocystic breasts which are are associated with enemy estrogen dominance type symptoms or uh issues and she also had a history of PCOS so that was I hope just gives you a little context as we go into testing then we’ll revisit her case so to talk a little bit about testing there are different ways to test hormones and I think it’s it’s good to be aware of the different types and the different advantages they have so blood testing is the most common it’s very reliable it’s often less expensive because it’s so routine but it is limited in that it’s one snapshot meaning it is your hormone levels at that moment on that day because hormones fluctuate very widely even throughout daily Cycles monthly Cycles it can be very dependent like when we’re catching it Can it could be harder doing things through blood there’s also saliva test which is mostly really reliable it’s easier to measure because you’re just spitting in a tube and it’s a lot easier to measure throughout the day and the month if needed so we can start having more frequent time points to get more information there’s also urine testing in general it’s less reliable for a lot of the hormones but it’s also real a lot easier and it’s the only way to measure metabolites of estrogen and these are basically estrogens that are broken down by the liver and there are certain types of estrogen metabolites that are more dangerous or more protective as far as risks like breast cancer and so it is a nice thing to look at especially when we’re in a phase of having higher estrogens when to test sex hormones so usually especially when we’re talking about doing blood testing we will usually test them on day three of the cycle or day 21. the reason that that’s in quotes is because not every woman has a perfect perfect 28 day cycle so really 20 uh day 21 cycle uh day 21 testing should be ideally seven days after ovulation maybe seven to ten days after ovulation and that’s I the goal of that is to catch Peak estrogen and progesterone levels after ovulation now this you know again there it makes it challenging when women have different lengths of Cycles already in the pre uh menopausal phase but especially in perimenopause it becomes a lot more challenging because we oftentimes don’t know what we’re catching when so that’s why it can be helpful to do some different types of testing I want to give some context this is some typical testing that I’ll order on a woman who’s woman who’s coming in to see me with perimenopause or even without perimenopause because it’s so helpful to get this comprehensive look especially when we’re in this time of higher risk of things like cardiovascular disease metabolic syndrome I find it so important to really look at the whole picture and not just treat the hormones the thyroid we’re really looking at the whole person and so taking all that into context and a lot of these things can can play a big part so even things like vitamin D levels have been shown to have a really big impact on our mood iron levels as well so so taking always into context I think is really important and then here’s an example of some specialty testing or functional testing that can be really helpful when we’re trying to figure out what’s going on this is a Dutch test which some of you might be familiar with this is a basically a way to look at hormones through a different lens be able to get a little bit more information so these basically these are some of the sex hormone levels like estrogiol progesterone testosterone and sort of like a dial where you’re seeing this is you know over the limit this is under the limit and we can also look at cortisol patterns which I’m not talking about much in the context of this talk but can also play a part with things and we can see a daily pattern of what’s going on we can kind of get more points in these you know hormones are not just Standalone that it’s a Cascade they’re one is converted into another one into another one and so we can get more information about these Pathways rather than just hormone levels and we can also see what I mentioned these estrogen metabolites so you see that estrogens are turned into these different types of estrogen metabolites and some are more concerning like for hydroxy estrone versus two hydroxyestrogen which it has more protective protective effect so again when we’re seeing a woman with higher estrogens either before perimenopause during perimenopause it can be helpful to see okay what are you what is your body doing with the estrogens and is it putting you at greater risk of something like breast cancer or other high estrogen issues Dutch also has this amazing option called cycle mapping where you can actually get more time points throughout the cycle to see what’s going on with the hormones and you can see here that we’re getting kind of this curve like we’re looking at the other pictures to be able to see okay what are your hormones doing throughout the cycle and this can give us again a lot of information if we’re trying to piece apart what’s going on what’s going on with your symptoms how can we treat you best be helpful and I didn’t I I wish I put a slide in here I didn’t put one in but they’re also more testing tests coming available that are direct consumer meaning you can just buy them yourselves one that I just started to look into is called anito and it’s a basically a little machine that you buy that you attach to your phone and has little test strips and allows you to actually test your hormones from home also so I again I’m just starting to look into it I haven’t had a chance to really use it a lot but I actually was just talking to a patient earlier today about it she had done it and I was like this is is really so helpful to be able to even do it from home and it’s a little bit less expensive so stay tuned check back in with me in the next month or so and I might have a lot more to say about it because I think again I I love tools that really give us more information and give women access to information about their health so to go back to Jessica so within a few visits she clearly she had more energy less bloating her periods had become more regular as a result of treatment we actually put her on cyclical progesterone meaning progesterone at certain times of the cycle and so her Cycles became more regular and a little bit less erratic and her hot flashes flashes had lessened a lot and and she was feeling sharp energetic and she was happy she’s like I feel great now given you know it’s not always black and white it isn’t always the hormones she had other things going on as well she had some heavy metals actually going on as well so that had it played into how she was feeling also but again that’s I I think that’s important to also note that it isn’t ever just our hormones just one thing going on oftentimes there are a lot of things going on we’re a human being that has a lot of complex things going on and so looking at the whole person is really an important piece also to addressing not only the perimenopause symptoms but someone’s overall quality of life and their overall health so with that I will finish the lecture part of this and open it up to questions and as you gather your questions and start typing them in the chat I want to give you a special offer as a thank you for joining us this evening and to make things a little bit more accessible to you I want to offer 20 off your first visit and if you call within November this month by the end of November and book an appointment at least by the end of January of 2023 then we’ll give you 20 off and the reason for this again I I feel like money can be a barrier or a good excuse that we have for not addressing our health so I want to take down that barrier a little bit and give you a little bit of incentive if you’re wondering about oh okay I’m not feeling so great I wonder if I if there is something going on should I really address this my answer is yes and you know just take this time to take care of yourself consider a Christmas present to yourself and really a good investment in your because again with some of those health risks the earlier we address them the better in decreasing things like our cardiovascular risk improving our bone health so there really isn’t time to waste and it’s not worth suffering you know through these symptoms when you could be feeling a lot better now and improving your overall health for the future so that is my Spiel for you and you can here’s our contact information here so yes so Nat asks do you accept Insurance great question we are not able to accept insurance for uh office visits but we can offer what’s called a super bill which is basically an invoice that has codes on it where you can request reimbursement from your insurance if you have a PPO a lot of testing can be covered by insurance as well particularly you know routine blood work through a lab like Quest or LabCorp and a lot of the functional tests that we use as well it will contract with insurance uh Margaret asks do you have any recommendations for liver support and proper estrogen metabolism when bioidentical estrogel in addition to taking dim great question it it depends a little bit on the context because there are different factors that can play into having an issue with detoxing extra estrogens so one factor could be our gut microbiome to not go into it too far basically some microbes create something called beta glucronidase which can mess with normal estrogen detoxification and if that is high in a woman number one we’d want to address those gut bacteria and fix the problem at the root but number two we could also use things like calci diclucarate which helps with that and prevents estrogens from being recycled into the body and you mentioned dim that helps kind of support the liver and getting rid of estrogens there’s also one called well indole-3 carbinol or i3c which is similar to dim in helping support that and honestly when it comes to detoxification in general some of the basics go a long way like making sure you’re pooping regularly making sure you’re staying well hydrated you’re limiting things coming into your liver like alcohol that’s another really common one alcoholism or heavier alcohol use is really common during the perimenopause phase and it doesn’t do a woman any favors because you’re going to raise up those estrogens it can mess with liver detoxification so that can be another one a just avoiding alcohol and taking good care of yourself eating all your broccoli and that um so let’s see next question how on Earth am I going to have sex with hubby without the risk of getting pregnant if all my hormones and Cycles are such chaos this is a great question so again and I maybe I didn’t have any one of the lecture slides but yes we can absolutely still get pregnant during this time so it’s important to have a conversation with your doctor about the best options for you because if you are relying on cycle tracking for knowing when you’re ovulating it can get a little bit more complicated and so if you’re struggling with that it’s important to have a conversation with your doctor and see if something like contrast you know oral contraception like the birth control pill starting to use a barrier method like condoms what is going to best support you from preventing pregnancy for women who still want to get pregnant during perimenopause that’s a good news because it means we absolutely can still get pregnant you know into our 40s women often do and so if that is their goal then we could also support them in that in that goal so yeah any thoughts on synthetic hormone medicine like T4 I hear it’s mainly a melee side effect free so T4 is if you’re talking about like T4 like the thyroid hormone that is usually called levothyroxine is a typical synthetic T4 a synthetic hormone replacement that’s thyroid hormone um that’s kind of a different conversation that’s really for addressing thyroid low thyroid function and yes thyroid function can play into this so that it is an option natural desiccated thyroid hormones are also a great option for a lot of women depends so so if they if you do have a low TSH low free thyroid hormones like free T4 and free T3 then that might be something to consider for pleading your hormones with either synthetic or natural hormone replacement and then oh you’d mentioned modified brand supplement any thoughts on this so it’s not one that I typically use I think I have seen it but it’s not one that I have used so typically the ones I’m recommending are professional grade just because I know that they have really good um quality measures as far as you know they’re doing third-party testing the levels are what they say they are um so usually I stick with those and then if they’re products that we can’t get through those companies then I’ll go outside of that and it may be that they have good but I just check with a company to see like what their quality standards are um and you know what their practices are great questions any other questions before we wrap up all right well again you know reach out to us if you’d like to schedule an appointment if you have any questions too if you’d like to have a conversation about what we do want to see if we’re a good fit and we do offer free 15-minute visits called Discovery calls where we can chat and just talk about your case and if you know we think that we would get some good results for you whatever will there be a replay of the presentation yes so for after registering for this webinar you’ll get the replay sent to you and you’ll have access to that you can also replay it so some of you are also watching the replay and hopefully you’re watching it within November I can take advantage of this as well all right well thank you so much for joining everyone I hope you all have a wonderful evening and happy holidays uh thank you so much for being with us take care foreign

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