Read the Episode Transcript
I'm Dr. Alexa Neynaber with Virasoap Natural Medicine, located in Meridian, Idaho.
I'm a naturopathic medical doctor and certified functional physician, and our
clinic specializes in natural health, wellness, and aesthetics for the whole human.
Today I have the wonderful opportunity to get to catch up with my friend from med school, Dr.
Andrea Emde.
Andrea, can you go ahead and introduce yourself a little bit?
hi, I'm Dr. Andrea Emde.
I am both a chiropractor and a naturopathic physician and I practice in Whitefish, Montana,
where I specialize in musculoskeletal injuries and hormone optimization for men and for women.
Can you see patients like crossover, like between the two sides of the practice?
Yes, and that's super fun because like I already know them and what's going
on with them So I feel like I already have a lot of history and rapport
built up with them And I feel like it really enhances their treatment plan.
I'm curious right now, what would you say you're seeing
the most on your chiropractic side of your practice?
And what are you seeing the most of in your ND side?
So in chiropractic, I'm seeing a lot of back pain and neck pain.
A lot of that, and then some also like pretty big disc herniations as well.
Some people just have radiating pain down their legs.
A lot of the neck pain issues are people who have been like going
camping a lot or have desk jobs same with the low back pain.
The biggest causes I've been seeing of it are people who just aren't moving
too much or working on projects that they've been putting off, and so
they're trying to get everything done in a day and they just overdo it.
On the ND side, I'm seeing a lot of patients for PRP or platelet rich plasma.
They're finally fed up with that chronic joint pain or arthritis that's just not going away.
And I'm also seeing a lot of people for hormone optimization.
So with hormone optimization, people are usually feeling tired, they want to lose weight, they're
not sleeping well, they're entering menopause, and they just need some extra help and support there.
The whole PRP injections into a joint space.
I, I'm so curious is it something that you do a one and done?
Is it a series of six?
What does it look like for someone when they have a
joint complaint of how many they're going to come in for?
Great question.
So that can vary with the condition itself and how degenerated that joint actually is.
So usually what I do is I will inject directly into the joint, but I'll
also address the surrounding structures because usually if the joint is
compromised, the tendons and ligaments that surround it are also damaged.
Previously, a lot of people would need anywhere from one to three
injections every two to three months, but now PRP has come so far.
A lot of my patients only need one injection and they feel fine.
So that's part of how I treat is I check in with them before, see
what's wrong, determine what their best treatment protocol is.
And then about six to eight weeks later, cause that's about how long it takes for PRP to
take full effect, I would do another check and visit and see if they need another injection.
And usually by that point, people are happy enough with their results,
they don't want another one because they're happy with how they're
feeling and how they're moving and what they can do, which is really cool.
So part of what makes the PRP so strong is I use a double spin method.
So the double spin method super concentrates those platelets, so it's extra potent.
That's cool.
I feel like that has to be a fairly long visit with just the kind of concept of being
like minor surgery, minor office procedure kind of concept, what does it look like
from the time you are prepping from someone coming into the time they're leaving?
Yeah, so for the first office appointment, that's just like a full history and
examination that can take anywhere from half an hour to an hour, just depending on
how much history is there that we need to know then the actual procedure, so it's
a blood draw from the patient that usually takes a couple minutes of their time.
And then for me, I need to spin it.
And that can take between 10 to 20 minutes.
There's different kits that require different amounts of blood.
So the more blood.
The more prep work that has to be done.
There's also one that's specifically for arthritis and that one needs extra processing as well.
And then when the patient comes back in the actual injections pretty
quick, I have an ultrasound that I use to help guide the needle.
I find the area and then inject it.
Send them on their way and I've either numb them up either right
after their blood draw or right before we do the injection.
And so the total patient time for that day is probably 10 15
minutes and the rest of it is just me getting everything ready
What a great amazing thing though for patients to be able to try something So relatively fast
relatively inexpensive comparatively to surgery and I never really thought about it going outside
of the joint space in that surrounding connective tissue that could also be helpful, but why not?
It's their own cells.
Exactly.
And so then we don't have to worry about any host interactions because it's all from the patient.
That's so cool.
Yeah.
And they also have no downtime with a PRP, no true downtime, like what you would have with surgery.
And so then the other part of your ND practice, what you're saying was like hormone optimization.
So is that kind of built into a bigger kind of primary care type
of idea or is it like really focusing in on hormone replacement?
So first visit is pretty all encompassing.
Being a naturopathic physician, I do like to take a very holistic approach
just to make sure you're not missing anything because hormone optimization also
looks a lot like thyroid imbalance or poor diet or mineral deficiency, so I
do a full intake with them, do a full blood panel, and that's the first visit.
And then usually it ends up being a hormone issue.
A lot of people have hormone issues because we burn the candle at both ends.
We don't eat well, we don't drink enough water, we don't sleep, et cetera, et cetera.
And then I give them different options of how we can go about addressing their hormone imbalance.
And that can range anywhere from diet, nutraceuticals, herbs, or even pharmaceuticals.
I work a lot with pellets because pellets has the least amount of work for the patient.
So they just come in, do the pellet procedure and then they're
done and they don't need to apply a messy cream every day.
I really try to not work with injections for hormones because those tend to be completely synthetic.
And so the body doesn't really recognize it as a usable substance.
And so you tend to get a lot of negative side effects with that.
That's why I prefer bioidentical hormones because you don't get as much of
a negative side effect profile as you do with the fully synthetic versions.
Totally.
Oh, I agree.
Hormones are a huge part of my practice.
I have read and heard lots of different clinical case studies of why pellets are so
great, and I'm so curious to pick your brain of what the conversion of the dosage of
a pellet is comparatively to like an oral or a troche or a transdermal application.
If I could avoid people being just on straight up testosterone cypionate
and the injection, I will, if you're going to do testosterone, it
isn't great to have this huge peak on just one day of the week.
And then it just keeps tapering down.
That doesn't make sense to my brain of what the body would do.
However, I feel like I'm very lucky here.
We have so many PCCA certified compounding pharmacies.
And they're so dialed of like how to get the creams right.
And how to get the oral preparations, where people like, aren't having like the feeling
of being messy or like feeling like it's so burdensome, but there's definitely people,
I'd be like, If this is not something you can be consistent with, I would much rather
you have the consistency of something that you don't have to worry about remembering.
So what is your process look like with hormones?
Like you, it's going to be a bigger conversation, trying to get that
holistic view of trying to address where is this issue coming from?
And hormones are going to be a huge part, especially in
patient populations who are in seasons of transition.
If I have, a pre menopausal or a perimenopausal woman, I might try to do
things without hormones before we're there, because I believe as much as
possible that they should have as much of their own cycling if they can.
If that's a possibility if it's not I definitely will get testing on
board and i'm prone to do serum based testing just because It's easier
to do more frequently if we want to compare something to something.
I always say that, your symptoms tell half the story, but you have to have
labs to tell the other, like it's really hard to just go by one or the other.
Personally, I like building a picture with both because I feel like I
get more of the complete picture and I'm a data nerd and I love that.
But my preference in the perimenopausal menopausal, season of life
would be to always use an oral progesterone and a transdermal estrogen.
There's always going to be exceptions to that rule, but I've just found
the best side effect profile, risk factor, family history, safe type
of interaction with these two hormones to create that yin and yang.
And then when it comes to testosterone for women, I would say I use
transdermal, but I'm definitely not opposed to them going and getting a pellet,
especially because the dosing is a little bit more straightforward there.
The only thing, and I'd love it if you could speak
to this because I'm not a pellet expert by any means.
One time I had a patient who told me she had a pellet for just
testosterone without any other hormones being given and no testing.
And she freaked out.
She had a huge anxiety attack.
The dosage was too much for her and then she couldn't go back.
The clinic told her.
She was stuck with it until it dissipated and it was time
for the next dosage which at that time they would go down.
This woman is no way, no how I'm really scared.
And this was a terrible first experience.
I want to try something else.
By no means do I think that is what's happening for majority of people who are getting
pellets, but I would love to hear your opinion of has that ever happened to you?
So I always get testing done.
I think that's very cavalier to prescribe a hormone because hormones affect your entire body.
Was she pre menopause, menopause?
She was perimenopausal.
Okay, so a lot of times with pellets, it's normal for perimenopause women to just get
testosterone because in perimenopause, as their estrogen goes through all these spikes.
So if you happen to pellet them when their estrogen is really high and you give them more
estrogen, it's going to create a whole host of issues and they're going to be very unhappy with it.
Interesting.
Are you saying that in that patient population, your timing when they're
going to receive their pellet based on whether they're out in their cycle?
In my premenopause women, yes, they do try to do that, but I also for
premenopause don't give them estrogen as a pellet because of that.
Cause they're at that sustained level and their body is already spiking estrogen.
Totally.
Yeah, as the pellet absorbs and releases estrogen into the system, if they get an
additional estrogen spike on top of the natural one, they're going to be very mad at you.
Yeah.
They'll have a lot of bloating, breast tenderness, moodiness.
It's going to be like the worst PMS ever.
I guess that also brings up a good question as majority of the
time, are you pelleting things in combination or are they separate?
Yeah, so for post menopausal women, I will do estrogen as well as testosterone.
Progesterone, I always do as an oral.
Again, everything has a caveat to it.
But typically I always do it as an oral.
For the pre menopausal women, I just do pellets with testosterone.
And then sometimes if they need it depending, On what's going on with them.
I will do like a topical for estrogen
makes total sense.
When you say that The patient population that could theoretically receive both like a post
menopausal patient is a pellet physically combined together like it's like a combination
just like we do combination creams with testosterone and estrogen in the same preparation.
Is it the same so they're just getting one pellet or is it two at the same time?
So it'll be multiple ones.
I'm not familiar with a pharmacy that does combine them together.
So what I typically do is like they make the testosterone
and the estrogen pills in different strengths.
So I'll do whichever one they need more than most closely resembles their dose.
And that's how you can individualize it to them.
Then I also usually highly advise them to take DIM to help metabolize extra hormones.
I loved DIM.
DIM's one of my favorite tools.
I have found, even in situations where we are not prescribing hormones, we are
just trying to re regulate someone's natural hormone production, there are so
many different types of patient populations that do well with adding DIM on board.
But specifically what I do is a preparation of a multi combination approach with DIM and a couple
of other liver support at the same time, where I essentially do like a washout period of just
a month where we try to clear out things that may have been held in the liver and things that
weren't getting packaged and broken down as well, and then put them on some sort of maintenance.
And my favorite personally for a maintenance DIM is like a DIM plus I3C just because you get all
the bases covered and just a little bit of vitamin e just to make sure for the absorption People
do well on one or the other if they liked those products and they wanted to stick with them.
But for whatever reason the theory of just having that one month where
you're really intensely hitting those other Detox pathways in the
liver, I've found that they're so much happier maintaining on just DIM.
I love that.
That's a great treatment plan.
So what aesthetic procedures are you doing right now?
it's so satisfying to use Morpheus eight, that is minimally
invasive, radiofrequency micro needling treatment.
That is probably my favorite aesthetic treatment to
do, just because you see really cool natural benefits.
You've seen it when you're working with PRP, but I am continuously reminded
about the power of stimulating your own biomarkers like collagen and how much
more profound and long lasting that is, then just placing something that is not
your body's, and it's just going to be there for such a short amount of time.
The morpheus treatment I'm mostly doing it for a lot of the same things you would
think of traditional microneedling in terms of smoothing resurfacing But it's doing it
in such a more powerful way that you're getting things like pore shrinking and you're
getting Fine lines and wrinkles that are softening you're seeing significant just
glow to someone's skin when they turn their head you're like I can't capture that in
a picture, but You see it from across the room .And then it has the other clearance
of what it is, it's called a SARD, which means it's a sub adipose remodeling device.
And so you're going to actually be able to shrink
tissue and help with that skin laxity, which is so cool.
So people have either had weight loss or maybe Had some changes in their face with the use
of filler and then not going back to filler where skin just feels a little bit pushed out.
It's a way to contract it back naturally because you're only using
heat and energy and your own stimulation of collagen and that matrix.
So that's cool.
The other ones that we're doing have built in comfort tools.
The laser hair, has a built in cooling tip.
When I was 19 and I had my whole body laser haired their numbing solution was ice.
They would ice your legs and your arms and be like, have fun.
Yikes.
I hated going to those appointments just because I was like, I'm just going to put ice on my skin.
And it was like legitimately in an OBGYN's office and it
was great, but the technology then is not what it is now.
And my device has a built in cooling tip.
So you can pre cool the skin, treat, and recool after most people don't even need that.
And then Lumecca is our IPL intense pulse light.
So it's a reduction of sun damage pigmentation.
Both the Browns and the Reds so think of the Browns like more of the sunspots and then the
Reds are more of like the cherries and vasculature a little bit near the surface Works on both.
Those are really cool therapies that you're offering.
It is very fun to offer something else that is giving people that benefit to how they are feeling
about themselves and they know they're not compromising their health while they're doing it.
And I think that just stays true to what you and I believe in
terms of why we bothered to do this Alternative form of medicine.
We want people to be able to use their own cells.
We want people to be able to find that naturalism for themselves without
having to rely on Chemicals ,without having to rely on toxic substances.
I really personally got into it because of PCOS patients and just the mental
load and burden that was happening in terms of hair growth that was not wanted.
And so that's been a total game changer for those patients.
What I didn't know, and now I know folliculitis, hugely beneficial with something like laser
hair removal, because you're removing literally the root of the hair that's causing the problem.
I had this one she like worked out a ton and she was so committed.
And she was like, I am so good about showering my yoga pants immediately after
but she had the worst folliculitis I think I've ever seen in her, bikini line.
And it was horrible.
Cause she was like, literally like underwear hurts, pants
hurt when I'm doing these exercises and it's slowing me down.
And so that, In terms of just like quality of life
change was so cool to see from an aesthetic procedure
you literally changed her life now She can go accomplish all her dreams.
Well I think she can push herself harder, that's for sure.
And she doesn't worry about it and she's certainly not worrying
about taking her kids to the pool anymore, which is also really cool
Have you seen a really big change in mental health
with these aesthetic procedures that you're offering?
Yes.
And I think that cannot be overstated about how, especially as women, but
men are not immune as well, we tie a lot of our mental, emotional health to
how we are doing self care and how we are presenting ourselves to the world.
And when that time preparation gets easier or literally you feel different about your own skin,
I think that is changing a lot of people's mentality on why they are bothering to do aesthetics.
I think so often it gets labeled as, aesthetic medicine is superficial
or it is, not actually medicine, but I would wholeheartedly disagree.
It is totally changing the way people are feeling about themselves.
Now you can get into the other side conversations of where
aesthetics majority is in our country with injectables.
And that's not what I'm doing.
And I'm not judging people who want to do that.
It's just my own personal, opinion and clinical decision to try to avoid that if possible.
But even with the things that are natural, I think people just being
able to feel confident in their own skin is indescribably helpful.
And that's just like one piece of the bigger puzzle, right?
You and I, we get to see so many different pieces of people's lives, which is unique
in the type of medicine we practice because as not only generalists, but specialists,
we are seeing into so many of these different parts of people's conditions.
And, we are seeing them say, wow, I never thought I could feel like this or
wow, my energy it's never been this high, I feel like I was in my teens again.
These little sound bites, I know you must have throughout
your day, especially when you practice physical medicine.
This type of additional thing on top of that?
It's just, we're just rounding out these really cool.
Tools in our toolbox for people.
What would you say is your favorite thing to do in terms of
just like time and time out spending with people in your office?
So it's different, right?
So it's chiropractic, the benefit is like almost immediate.
So I think on the chiropractic side, my favorite thing to do is a neck adjustment
because you can do the neck adjustment and then you just see people relax.
It's instant and it's satisfying and they feel good because you can see it and they tell you too.
And so that's really cool.
And then I think on the ND side, it's like a slower change, right?
Because it's natural.
It takes time.
I think it's like when they say they have their life back, or they
never thought they were going to feel this way again, or they didn't
realize how bad they felt until they realized they could feel this good.
Those little things are huge.
And that makes everything just so rewarding and really reminds me this is why I did this.
Would you say you hear that equally amongst the
perspective of doing joint support versus hormone support?
Yes, I do.
And that's really cool too.
Cause I can't say one branch of medicine is better or works better for some people than the other.
Cause they both have such an important role in health.
And I bet there are people who would benefit from all of it, especially like those
people who are so active or especially active in those seasons of transition.
Yep.
Those are my happiest patients.
The ones who do both.
What's your favorite that you offer?
It's a tough choice but I'd say IVs.
I can't pick between iron or vitamin C.
They both have special places in my heart.
I see a lot more iron just because so many people are iron deficient.
And those are so often the women who have been told for so long that
they were fine, that Their energy is just that part of being a mom
or, Oh, you just don't sleep well enough or just need to lose weight.
And so like these mood things, they're probably just in your head , here take an antidepressant.
I can point to 85 percent of those cases coming back to iron.
But I'm not exaggerating when I say those 85 percent of women will
say things like, I did not understand the baseline of how tired I was
because now I know what energy is, or I haven't felt this way in years.
And it's sad because this is a medication that should be used more
often in standard of care in, Primary care medicine or in OBGYN care
or in situations where people go into an emergency care situation.
It gets pushed to the back burner and it oftentimes just shifts into this
conversation where if someone needs iron, let's just give them oral iron.
But that has its problems and most people don't stick with it because they feel terrible on it.
Most people, when they get an IV iron, they're like, I don't necessarily
feel anything today, especially not with the first treatment.
They might feel a little fatigued actually that day, it's metal, it's inflammatory, there's
no getting around it, but if you use the right type, and it's low dose, and it's safe, and
it's encompassed in a sugar molecule, People don't have those crazy inflammatory reactions.
The product I use in my office is actually safe in pregnancy and people in dialysis.
If you treat those two patient populations with the treatment,
it's going to be very safe for a very large population.
So how are you finding so much iron deficiency?
Are you doing different testing than traditional doctors?
I'd say the simplest way that is such low hanging fruit that should
be adopted by more people who are running annual labs or specifically
women's health labs is never overlook the iron panel with the ferritin.
That is so important.
A CBC will only tell you is it iron deficiency versus some other type, but you just don't know.
And there's so much research now that points to even iron deficiency, not only leading to
iron deficiency anemia, but being a problem in and of itself for mental, emotional wellness.
I don't understand why we're not utilizing it more, because in my opinion, a one time series
of iron that builds up your levels and then you maintain with diet and lifestyle, isn't that
more cost effective than taking an antidepressant every day for years or like safer in the
sense that if you wanted to go through a fertility journey in that time, you wouldn't have
to start and stop your medication or something, Even feel the burden of making that choice.
I feel like just strictly as a woman, I'm biased towards this conversation, but I
feel like it is one of the most life changing things because it's so overlooked.
And so a lot of providers will actually refer patients to me just in our infusion room.
And then I will send them back because I just want to be that easy
stepping stone in their care plan of what makes people feel better faster.
And they love me for that because their people do.
And I don't want to get in the way of what those practitioners are doing
in their world and their care brain for those people's treatment plans.
But if I can be a reason that someone has access to the safest type
of iron and the type of iron that they will do I'm here for it.
Literally but yeah.
I see, unfortunately, also the people who have negative experiences with IV iron in
hospital type settings or much, much larger doses than they ever should have received.
And do you think a lot of that's because of the form that perhaps they don't have, the safe form?
Again, I think it comes back to insurance that they really often only want
to pay for products like 350 milligrams, 750 milligrams, or even double that.
We're doing 100 or 200 milligrams by comparison.
So dosage alone, yes, you need more of them, but I say at what cost is
something like that could send someone into an autoimmune flare or could send
someone into a much higher chance of an allergic reaction, worse anaphylactic.
We already have a bad reputation in the infusion world for risk and mitigating risk is everything
to me, if we're trying to do something that is better in the wellness of someone, why take that
undue risk, especially when there are Alternatives out there . With Insurance, we keep coming
back to this place where, yeah, they will pay for this one, but is that what you want to do?
Exactly.
Is that a conversation you have often with people, the insurance one?
Yes.
Especially on the chiropractic side, because we have a population have been so conditioned
to use our insurance that people just want to use it because like they pay into it.
So I totally get it.
You want to use it.
Yeah.
But most of the time, It's cheaper for the patient to pay cash rather than insurance.
And then like PRP, the actual injection is not covered by most insurances and same with the HRT.
Sometimes they'll cover the creams for estrogen, but not everyone needs the creams or like they'll
just cover the testosterone injections, which as we talked about, usually aren't the best option.
Yeah, it's a tough conversation.
The one that I typically need to have multiple times because people
don't want to believe that The insurance isn't going to help them.
And I get that.
It's tough to hear like something you've been paying into for years isn't it the best option?
It's frustrating.
Yeah.
I'm curious how much we will have seen the evolution of insurance in our lifetime.
Before we were students to the time we were in school to the time we've
been practicing, we've already seen these massive shifts back and forth.
But at least as of now, I would agree with you that majority of people around me, they've been
paying into something and they feel that desire of not wanting to waste it, but at the same time,
when they get into the actual benefits of what they will get reimbursed for, it's very poor.
It's very unfortunate.
I would say if you have insurance, try to use it for certain things.
And I don't want to take anything away from that, but the reality is they will not
reimburse providers who are actually willing to spend that time with people and will not
pay for the types of products that we believe are going to not cause more harm to a body.