How to Optimize Female Hormone Health for Vitality & Longevity | Dr. Sara Gottfried

welcome to the huberman Lab podcast

where we discuss science and

science-based tools for everyday

[Music]

life I'm Andrew huberman and I'm a

professor of neurobiology and

Opthalmology at Stanford school of

medicine today my guest is Dr Sarah

gotfried Dr Sarah gotfried is an

obstetrician gynecologist who did her

undergraduate training in bioengineering

at the University of Washington in

Seattle she then completed her medical

training at Harvard Medical School and

she currently is a clinical Prof

professor of Integrative Medicine and

nutritional Sciences at Thomas Jefferson

University she has also been a clinician

treating men and women in various

aspects of Hormone Health and Longevity

for more than 20 years she is an expert

in not just traditional medicine as it

relates to hormones and fertility but

also nutritional practices

supplementation and behavioral practices

and combining all of that expertise in

order to help women navigate every

aspect and dimension of their hormones

longevity and vitality ranging from

puberty to Young adulthood adulthood

perimenopause and menopause and nowadays

she's also treating men across the

lifespan in terms of longevity vitality

and Hormone Health during today's

discussion Dr gried shares an enormous

amount of information and tools that

women can apply toward their Hormone

Health fertility vitality and Longevity

we discussed the gut microbiome which

many people have heard about but Dr

Godfrey points out the specific needs

that women have in terms of managing

their gut microbiome and the ways that

that influences things like estrogen

levels and Metabolism testosterone

thyroid and growth hormone and much more

we also discuss nutrition and exercise

we touch on how the omega-3 fatty acids

play a particularly important role in

managing female hormone Health Dr gried

points out why women have particular

needs when it comes to essential fatty

acids and how best to obtain those

essential fatty acids for Hormone Health

we also discuss exercise and she offers

some surprising information about the

types ratios of resistance training to

cardiovascular training that women ought

to use in order to maximize their

Hormone Health we also talk a lot about

the digestive system this was a

surprising aspect of the conversation I

did not anticipate Dr gried shared with

us for instance that women suffer from

digestive issues at more than 10 times

the frequency that do men and

fortunately that there are tools

specific to women that they can use in

order to overcome those digestive issues

and that in overcoming those digestive

issues they can overcome many of the

related hormone issues that so many

women face Dr gried also shares with you

tremendous knowledge about the specific

types of tests not just blood tests but

also urine and microbiome tests that

women can use in order to really get a

clear understanding of their hormone

status not just of present but also

where the trajectory of their hormones

is taking them so we have an avid

discussion about puberty about young

adulthood adulthood per menopause and

how best to manage and navigate per

menopause and menop pause including a

discussion about hormone replacement

therapy in addition to her academic and

clinical expertise Dr gotfried has

authored many important books on

nutrition hormones and supplementation

as it relates to women and to people

generally the two books that I'd like to

highlight and that we' provided links to

in the show note captions are women food

and hormones and the hormone cure I read

the hormone cure and found it to be

tremendously interesting and informative

not just in terms of teaching me about

female hormone health and various

treatments for female hormone Health but

also as a man trying to understand how

the endocrine system interacts with

mindset nutrition and supplementation

more generally so I highly recommend the

hormone cure for anybody interested in

hormones and Hormone Health and women

food and hormones in particular for

women although again both books are

going to be strongly informative for

women wishing to optimize their Hormone

Health vitality and Longevity before we

begin I'd like to emphasize that this

podcast is separate for my teaching and

research roles at Stanford it is however

part of my desire and effort to bring

zero cost to consumer information about

science and science related tools to the

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huberman and now for my discussion with

Dr Sarah gotfried Dr gotfried Sarah

welcome thank you so happy to be here

yeah I'm delighted and very excited to

ask you about an enormous number of

topics you are expert in so so many

things so uh the challenge for me is

going to be to uh constrain this walk as

it were but uh I'm hoping that we can

touch on a great number of things today

the first of which is really about

hormones and female hormones in

particular and I have a question which

is is it ever informative for a woman

regardless of age to know something

about her mother's perhaps even her

grandmother's experience VIs V hormones

not just pregnancy challenges with or um

ease with pregnancy and child rearing

child birth this sort of thing but you

know what sorts of conversations should

women be having with themselves and with

family members to get a window into what

their specific needs might be love this

question so my work is really at

interface between genetics and

environment so your question gets to

both

and I think it's essential that you

understand what your grandmother went

through I'd even say your

great-grandmother depending on longevity

in your family so I grew up with my

great-grandmother I get that and

especially your mother so I would

probably start first with trauma an

intergenerational trauma because I think

that affects the endocrine system so

hugely especially cortisol signaling but

the broader Pine system Psycho imuno

neuroendocrine

System and then there's you know if I

think

about the stages the life cycle that a

woman goes

through if you think about puberty I

think I don't know how genetically

determined the age of puberty is

certainly there's a lot of environmental

influences like toxins can affect it but

um

pregnancy the age at which you start to

go through per menopause menopause many

of those have a genetic component so

with pregnancy I mean you can certainly

think the shape of the pelvis your

ability to have a vaginal birth some of

that is genetically determined I mean

you do have you know the the sperm donor

affecting some of that but you know in

my family for instance we have no

cesarian sections so everyone goes

through this process of a relatively

easy national birth I was a forceps baby

but you know for the most part um you

can find out about that and then there's

certain female conditions that have a

very strong component genetically most

of which run in my family so that

includes enmet

trios fibroids I just had a hysterectomy

I had a 50 plus

fibroids and uh polycystic ovarian

syndrome and of those three uh how fre

are those and um maybe I can constrain

the question a little bit by saying um

today's discussion I imagine is going to

be heard by men and women of all sorts

of Ages so I um maybe I'll direct the

question a little bit toward you know at

what age should these discussions start

um you know we always imagine that uh

women in their um 30s and 40s and 50s

and onward should be getting certain

tests and um addressing things like uh

ovarian reserve and and other sorts of

things but you know maybe we could March

through and just say for a woman in her

teens who's already hit puberty what

sorts of biomarkers whether not their

blood-based or per or um phenotyping you

know the outward appearance of uh should

those young women be paying attention to

likewise for women in their 20s 30s

maybe we could take it a more or less by

by decade at starting at puberty

assuming that woman hits puberty

sometime what between what is it now the

average in the US is somewhere between

12 and 16 years years old do I have that

right no you do not oh great I love to

be wrong so so it used to be 12 to 16 I

would say 50 years

ago it's been moving younger and we

think some of that is related to toxin

exposure as I mentioned but I was 10

when I went through puberty so uh well I

should say menarchy and I started

growing breasts much before that so I

think

now I'm going to step away from the

science for a moment I'm going to do

that pretty fluidly and I'll try to call

it out I think there's also a huge

influence from

stress and like the development of the

adrenal glands so going back to the

science the issue in teenage years is

that the hypothalamic pituitary adrenal

axis and I like to think of it broader

so stay with me I hypothalamic pituitary

adrenal gatal over recent women testes

and Men

thyroid gut axis so that to me is the

control system so I'm kind of expressing

my bioengineering side here well I think

it's great to include the other organs

and tissue systems of the body because

as we both know that the narrow

definition of just hypothalamic

pituitary adrenal it can't be just that

right no it can't right no yeah it

doesn't tell the whole story so if you

look

at the the main sex hormones in a a

young woman who's in her teenage years

the hypothalamic pituitary adrenal gatal

part of that is not fully mature so

they're more likely to skip periods

especially under stress they have a lot

of influences that really doesn't get

well established until you're done with

adolesence and I'm told that adolescence

now is till like age 25 to 26 I heard

that I was like I've got two daughters

and I was thinking that's a really long

time not just psychologically defined or

bio psych mostly mostly psychologically

defined I heard that from a

psychologist

so biomarkers you asked about in your

teenage years what I think is really

interesting is to look at

cortisol to look at the dance between

estrogen and progesterone in those years

is less helpful because I I think

there's a lot of variability due to the

immaturity of the system if you've got

someone who's got really regular periods

it's probably better to do some

benchmarking at that age but generally I

find that

benchmarking is best performed in your

20s or 30s are periods not that regular

in terms of duration of the menstrual

cycle when the menstrual cycle first

sets in it depends so I was like

clockwork every 28 days until I had my

hysterectomy in August

same thing with my daughters I've got

two daughters one's 17 the other's

23 for a lot of women they're not

regular and then there's the whole piece

of oral contraceptives and other forms

of contraception where you have no idea

what the normal cycle is and I hope

we'll have some time to talk a little

bit about oral contraceptives because I

think it is this is now opinion again

and not science I think it is the number

one endocrinopathy

that is iatrogenic for women uh we will

definitely talk about I get a lot of

questions about oral contraceptives um

in the social media space and also

questions about iuds quite a lot totally

in particular copper iuds non non-

hormonal iuds so we will definitely

touch on that I'm an IUD Crusader so I

just want to you know give you that

warning you're you're a fan do I have

that right or you're anti I'm a huge fan

uhuh which iuds in particular so I like

copper because it's non hormonal it's as

effective as getting your tubes died who

would have thought it's that toxic to

the sperm Mobility is that how it works

that's my understanding of it is that

that it that it basically it's like a uh

more or less an electric fence to the

the sperm cap and just that's it

electric fence is a bit of a harsh

analogy but I'll work with that but it's

you know to have something that can last

for 10 years so that you really have

complete autonomy and sovereignty over

your sexual life that's profound and to

not get all those Downstream risks that

are associated with birth control pill

the other thing that's important to know

about it I know this is a

zore women who use the copper IUD have

the highest satisfaction rate of anyone

on contraceptives the highest

satisfaction rate and yet it is the

least used of all forms of interception

now my favorite is

vasectomy but short of vasectomy I think

the IID is a really great choice there

are some risks associated with it I'm

not saying it's risk-free but I love the

ID and I love it for younger women too

because it used to be that when I went

through my training which was 30 years

ago we were told you know don't put it

in someone who hasn't had a baby and

that is patriarchal messaging but

getting back to your original question

which is about biomark per

decade in your

20s that's when you want to do some base

casing with estrogen progesterone and

testosterone so I think it's really

helpful to know about this this Tango

you're from Argentina or your father I

have Argentine lineage yes yeah my

grandparents did Tango into their late

80s I I am I'm in my late 40s and I I

still haven't started so I suppose

there's time it might be time for you to

that okay and it might be a factor in

their longevity do they have good health

span not justan and my grandfather

Smoked Cigarettes daily remained

mentally sharp until he died in his late

90s but um almost burned down their

apartment several times falling asleep

with a cigarette in his mouth so I don't

recommend anyone Smoke by the way uh but

it was uh coffee mate red meat and

cigarettes and they lived into their 90s

so that side of my family has the

genetic Advantage the other side less so

um but in any event um Tango um is a is

a 2023 goal it has been every year um

the uh I'm gonna hold you accountable to

that okay we'll do and there no there

will be no YouTube video of me doing

thing at least not initially Tim Ferris

actually a phenomenal podcaster as we

know is a he's a badass he's a badass

Tango Tango dancer I know this through

various sources yes yeah I've seen yeah

so this Tango between estrogen and

progesterone is incredibly important you

want to have the the right lead you want

to have the right follow between the two

hormones again I'm stepping away from my

science hat but what happens a lot of

the time is that estrogen dominates in

that Tango and when that happens it sets

you up for a greater risk of fibroids

enetri posis breast

pain probably in association with the

microbiome in the estrobolome oh can you

familiarize me with the estrobolome

I'm delighted know that I don't

recognize the term yeah so the

estrobolome is the set of

microbes in and their DNA their DNA

mostly in the gut microbiome that set of

microbes in their DNA so it's in the if

you look at the

totality the subset of particular

bacteria modulate estrogen

levels so a lot of this work was

spearheaded by Martin Blazer

and what we know is that there are some

women who have an estrobolome that makes

them have a greater risk of certain

estrogen

mediated conditions like breast cancer

and amral cancer and in men prostate

cancer so the estrom is incredibly

important there's not a lot of attention

paid to it but I always think in terms

of my patients you know could this be

someone who's got faulty estrobolome and

we need to adjust it with you know some

of the

microbiome uh

modulating uh nutrients nutrical that we

have so that they're less likely to have

that that Tango that's not working with

estrogen and progesterone so getting

back to the

biomarkers if if you gave me an

unlimited budget which I kind of have

with some of my um clients that I work

with now what I would want to know is

estrogen progesterone testosterone and I

want the timing right for that I'd want

to know about DHEA and sort of the whole

Androgen pathway I'd want to know about

the metabolites of estrogen because some

of them are protective and very helpful

others are a bit like Homer Simpson I

mean they are just like causing all

kinds of problems in your body

increasing the risk of Quinones like d

damage and potentially an increased risk

of breast cancer although that data I

think is

mixed I'd also like to know about their

stool so I want to know about the

microbiome so the best that we have

right now is to look uh when we do stool

testing and I do a lot of stool testing

we can look at things like beta

glucuronidase are you familiar with BG

I'm familiar with it as a term and so

for those listening it very often not

always when you hear an acea you're

dealing with an enzyme so we can take a

stab there and and it sounds like it's

somehow involved in um glucose

metabolism of some sort or is it

glucuronidation so it's involved in when

you produce estrogen in the

body this is like the simplified version

but when you produce estrogen you are

meant to use it like send it to The

receptors where it's meant to go and

then lose it like you don't want to keep

recirculating estrogen like Bad Karma

and that's what happens with people who

have high bet beta glucuronidase so it's

this enzyme that's produced by three

bacteria in particular in the gut and I

see a lot of men and women who have

elevated beta glucuronidase and then

they have some estrogen dominance

related to that is that the total reason

we don't really know but it's one of the

drivers it's one of the levers and it

can be detected from a microbiome AK

stool sample that's right and terms of

blood testing or various tests for these

other biomarkers getting estrogen

testosterone and other ratios I I

realize there are people have different

means financial means but in general

people wanting to do a blood test it

sounds like they're going to need to do

it what women will need to do it at

different stages of their menstrual

cycle if they had to pick one you know

either in the follicular phase and or in

the ludal stage of their ovarian

menstrual cycle excuse me ovulatory

menstrual cycle when would you suggest

they do that if they had to pick one so

if you forced me to pick one I would say

probably day 21 to 22 for someone in her

20s so we're focused right now on that

decade so for most women they've got a

menstrual cycle date that averages out

at 28 days so this is about a week

before they start their period for women

who are more regular it's harder to do

that as women get older and we'll talk

about this in a moment usually the the

cycle gets a little shorter so as they

start to decline in their progesterone

production their period gets a little

closer together like mine before August

was about every 26 days

so at that point you want to test sooner

like day 19 20 and I'm not talking about

a blood test so a blood test is the

cheapest thing it's usually what's

covered by insurance but my preference

would be to do dried urine I like to use

saliva for cortisol I like to use dried

urine so that I get metabolomics in

addition to the levels of these hormones

and if I'm forced to I'll use blood

testing and that's certainly the gold

standard for all of these hormones that

we're talking

about but um it's not as comprehensive

and as you know it's a quick little

snapshot while the needle's in your vein

for you know 30 seconds yeah the

salivary cortisol makes sense to me

because my understanding is that you get

free cortisol which is the active

cortisol you said with urine you're also

getting the metabolites that's right and

then um

for blood testing you're getting sort of

a crude window into the averages a

static total

level so uh let me go back and say one

other thing about biomarkers a big part

of the testing that I do in phenotyping

my patients I practice Precision

medicine so I I like

to almost start with nutritional

testing I don't think I've ever had a

teenager I've got some NBA players that

are 19 20 21 so maybe those count but uh

those are men obviously but for

nutritional

testing that would be potentially a

helpful thing to do in your 20s becomes

less important as you get older and you

develop more micronutrient deficiencies

but micronutrients play a huge role in

terms of hormone production magnesium

you know the Magnesium is hugely

involved in the way that you get rid of

estrogen as an example so micronutrient

testing what I usually do is a

combination of blood and

urine and so I'm looking at all of the

micronutrients that we can measure that

have some clinical scientific basis

behind

them if I could do that for a teenager I

think it might be helpful

because I recently gave a lecture on

breast cancer RIS

reduction another quick

sidebar and I was sad to find that

intake of vegetables polyphenols is such

an important predictor of future risk of

breast cancer like when you're 50 60

plus and the most important time is when

you're a teenager now I have one

daughter that eats vegetables she loves

them and I have another daughter who

eats food that's beige and it's very

hard to get her to eat the volume of

vegetables you know five colors a day

which is what I do

and if you have

evidence that you could show a

17-year-old that they've got

micronutrient

gaps I think that would be a motivator

for them to eat differently at a time

when it's so

critical even though it's you know 25

years in the future that it's going to

potentially change this Arc that they're

on what do you do for a young woman who

doesn't like vegetables is or is not

somehow able or willing to to get those

five colors a day of vegetable to help

support the

microbiome you know are supplements a

useful tool in that case um what other

sorts of tools Behavioral or otherwise

are useful such a good question so here

I'm going to invoke Rob Knight at

UCSD so I think his his uh his gut

project has really been helpful in terms

of understanding what kind of modulators

are going to be

important so what I try to get that

person to do and I don't see many teens

anymore other than NBA players what I

try to get them to do is to have a

smoothie very hard to get them to have a

smoothie every day but if I could get

them to have a smoothie three times a

week and to throw some of these

vegetables in that makes a huge

difference I mean we know that makes a

difference in terms of microbiome change

she be blending up broccoli or kale

cauliflower so cauliflower great even

they're putting things into the Smoothie

yeah I don't know if you can get a

teenager to do that but they often will

use like I have them do steamed broccoli

that's in the freezer because it's got

very little taste so that they could do

that in a chocolate smoothie they could

add some greens I like greens powders

are was super convenient so that with

you know kind of a a taste that they

like whether that's chocolate which is

what most of my clients want or you know

vanilla with berries and that sort of

thing so that can go a long way if you

don't like vegetables and short of that

I would say some supplements but I would

say that's a distant second to making a

smoothie I've got one patient that I

have to mention because

um he took this to the extreme so he's a

retired physicist professor at

UCSD he found out that his microbiome

was a hot mess and um developed

autoimmune disease and so he became

hellbent like only a physicist could on

changing his microbiome and he

dramatically shifted it by having a

smoothie every day with

57 vegetables and fruits in it 57

independent 57 independent so I mean

this just warms my heart the way that he

did this but he would go to the farmers

market he would just get a bunch of this

a bunch of that and he would go home

make the smoothie and then stick it in

the freezer so he'd have a serving every

day and he became a completely different

person

based on this microbiome change his uh

autoimmune disease is in

remission he um he dropped a huge amount

of weight he went from being you know

kind of this phenotype that I know you

know well of a professor High performing

traveling around the world on so many

boards so much Innovation so many great

ideas super computer guy to being

someone who gets up in the morning gets

in his hot tub EX exercises for like 1

to two hours a day and then does a

little work like he completely shifted

the way that he lives and his microbiome

shift you know who knows what what's the

chicken and what the what's the egg

there but he had a huge change in his

physiology glucose went from being quite

high he had and he tracks all of this of

course it's like on S after all right

and retired I suppose might have had and

he's retired but he's he's got the

Longest Time series of anyone I know and

he's tracked his glucose and Insulin

going back 20 years so he can show you

okay here's where I started having my

smoothie and here's how my glucose and

Insulin changed as a result of that I'd

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um using over-the-counter probiotics as

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that excessive doses of capsule

probiotics can give a brain fog like

condition um I personally don't use

capsule probiotics unless I feel like my

system is under a significant amount of

stress in which case I might add that in

for brief periods of time or if I've

just taken antibiotics for a period of

time right uh do you ever recommend that

the college student or the high school

student that she or he take capsule

probiotics assuming that they're getting

let's say three to five servings of

vegetables per day either in smoothie

form or some other form what are your

thoughts on on supplementing

probiotics it sounds like such a simple

question it is such a complex answer and

I don't think we really have the answer

so I'll tell you the way that I approach

it I look for randomized trials to

support my use of probiotics and frankly

I'm

underwhelmed so I've seen some data if I

invoke my um NBA players for a

moment almost every player I've tested

has increased intestinal permeability

they just have such a high training load

probably mediated by cortisol very high

glucoses when they drain that they have

increased intestinal permeability so

those tight junctions in their intestine

become loose they develop a lot of

inflammation as a result of that and

when you're a professional NBA player

and you're making 20 million a year like

you don't want a lot of inflammation you

want a little bit to like help your

muscles recover but you don't want it to

be um adding to problems when you

develop an injury so this is leaky gut

leaky gut I don't love that term but

yeah we'll use it here so there's a

there's a particular probiotic that is

helpful in athletes with leaky gut so

that's the kind of specificity and

randomized trial that I'm looking for

the rest of

it I think there's support if you find

help from it as you described if you

take a course of antibiotics I mean

first of all I would question whether

you need them but I try and avoid them

there there have been instances where

they've been prescribed and I took them

mostly in the past I was in college they

seem like they kind of gave them out you

had a sinus infection they give you you

know antibiotics you like yeah the worst

treatment ever yeah so if you're coming

off of antibiotics I think that's a good

time to do what we call replacement dose

Pro biotics I think what's far more

interesting

is

prebiotics I think the data is much

better for

prebiotics and um The Selective use of

polyphenols how would a person in their

teens and 20s or any age for that matter

know what whether or not they have

nutritional deficiencies what is the

best way to analyze if one is getting

enough magnesium um and for that matter

what is going to be the best way to test

the

microbiome you said stool sample it and

I'll come right back with the same

question I asked about blood

test what time of day when during the

month um to establish this a baseline so

this would be prior to embarking on a

you know 97 vegetables or how per day

it's only 57 well I love the idea that

you're telling us if I'm gathering

correctly is that yes there's a case for

probiotics but for the typical person

regardless of age eating more vegetables

or drinking more vegetables as as the

case may be is going to be beneficial

for the gut microbiome perhaps without

the need to go test whether or not one

is making a certain number of estrogen

related metabolites or not just that

that's a great starting Place eat or

consume more vegetables totally um but

if one wants to analyze their gut

microbiome are there good tests

available to the general public this has

been I'm not going to name companies but

I've been tracking this over the years

and it's never been clear to me that we

know what constituents of the gut

microbiome are are best you we know that

dis is is bad and we know that diversity

of the microbiome is good we hear this

but no one's ever told me that you want

a particular ratio of one microbiota to

another right in a way that has made any

sense to me at least totally um I'm not

a microbiologist but whereas with you

know with testosterone and Men we hear

okay you want your free testosterone to

be about 2% of your total perhaps with

women you women are going to have more

testosterone than estrogen on average

but still less than men when you look at

testosterone it's ET Etc but you can

kind and get some some crude measures

but for the microbiome it just seems

like long lists of microbiota for which

um I just get dizzy I just if you just

wrote out a bunch of I's and L's and s's

you'd kind halfway you getting a bit bit

the same information I'm not trying to

poke at that field it's a beautiful

field but they haven't told me what to

what I what my microbiota ought to look

like like what's a healthy microbiome

chart well that's because we don't

know I mean the best we have is Rob

nights work but even even that is

limited in terms of you know can I tell

you that a a woman in her 20s should

have this particular pattern with her

microbiome no I can't so um let me go to

your first question because I think you

just asked about six your first question

is about nutritional testing what I like

to do with nutritional testing is run a

panel that's looking at antioxidants so

like vitamin A vitamin C Alpha lip IC

acid um plant-based antioxidants CU you

can measure that in the blood I like to

look at some of the key vitamins

especially the B vitamin range because

as you probably know if you've got

particular genetic um polymorphisms you

might be less likely to be absorbing the

right level of vitamin B9 folate vitamin

B12

Etc um I'm also looking going back to

the antioxidants at glutathione because

I think that's such an important lever

when it comes to detoxification which we

haven't talked about yet and then I'm

looking at some of the Minerals

Magnesium is really the most important

and we know that somewhere around 70 to

80% of Americans are deficient in

magnesium that's like the the lowest

hanging fruit I would be curious for

instance like with magnesium if that

number of people are deficient does that

mean that that number of people should

be targeting their nutrition towards

foods that contain magnesium and or

supplementing with magnesium and if so

what forms of magnesium we've talked

about mag 3 and eight SLE there's a

magit there's so many forms can be a

little bit of overwhelming to people so

any any detail um in sourcing would

appreciate it great so first in terms of

testing what I prefer to do is to

mention one more than one lab and more

than one brand um and I can just I'm

speaking mostly from experience so uh

for testing I do a lot of goova

neutrals during the pandemic they

developed an at home tests normally with

a neutral you have to get your blood

drawn and you have to do a urine sample

so a lot of people can't do that the

great thing about this test is your

insurance usually pays for most of it

and so the co-pay is about

$150 so during the pandemic they

developed another test called

metabolomics which does much of the same

testing but it's a finger

prick so most of my patients prefer that

in fact they haven't gone back to the

neutral second lab is Spectra cell I use

Spectra cell occasionally I find it not

quite as easy in terms of fitting into

my practice but I've got friends and

mentors like Mark Houston who does a lot

of uh kind of precision um cardi

metabolic Health he thinks spectrol is

the best test out there so you asked

about

magnesium you have to measure red blood

cell magnesium like whole blood and with

deficiency

it's interesting with

supplementation for my patients who tend

toward constipation and that's frankly

about 80% of the women that I take care

of really yes wow I'd be curious as to

why that that is um is it I I can guess

uh diet

stress um

patriarchy

rage so psychos psych so Pine the um the

pine system right psych psych olog

Immunology neural and endocrine factors

combined is it yes and then I would say

there's another

factor which

is being female is a health

hazard so we've twice the rate of

depression insomnia we've got 3 to 4X

increased risk of multiple

sclerosis we've got 5 to8 times the risk

of thyroid

dysfunction so if you just look at that

and you look at subtle preclinical

thyroid dysfunction a huge number of the

women that I take care of well let me

back off a large number of the women

that I take care of have thyroid

dysfunction that's contributing to

constipation and if we go back to that

control system the hypothalamic

pituitary adrenal thyroid gatal gut

AIS and they have a lot of perceived

stress together with this borderline

thyroid function that no mainstream

medicine doctor has told her is a

problem and then she's got a problem

with the Tango between estrogen and

progesterone she's going to tend toward

constipation women have a lot more

constipation than men the gut is about

10t longer in women compared to men we

should talk about some sex and gender

differences and Define those sure and

they are much more likely to have a

torturous colon and the way you know

that is you get a colonoscopy and they

tell you yeah it's really hard to like

get in there do what we need to do as a

brief tangent but I think this is the

time to ask um what at what age now do

Physicians insists their female patients

get colonoscopies uh for men I think the

age used to be 50 now it's getting

ratcheted back to 45 or 40 again these

are recommendations not requirements but

they're pretty strong recommendations

from depending on where you live Etc um

for women how early do you think they

should get a colonoscopy to to explore

for possible pops Andor colon cancer

yeah it's a really good question I don't

know the answer so what I've always

operated with is 50 the way that I

answer that is to go to the US

preventive task force rating to

determine based on their synthesis of

the data what age is the most

appropriate has it changed as you just

described for men from 50 to younger I

don't know so we should fact check that

all these um additional health hazards

for women um you mentioned some some of

the you broadly mentioned psychological

impact right and and of course these

things are all related psychology

immunology and one of the I think

wonderful things about neuroscience and

Science in general and medicine is that

there's now an an understanding that all

the organs are connected to one another

it's a network it's a network and then

the microbiome sits at at um at a key

node within that Network um and I think

most people accept that now yes you it

that seems to be a theme that at least

in the last 10 years is really wonderful

because um certainly for Neuroscience it

was thought that you know unless it's in

the cranial Vault it's not neural which

is ridiculous because there's lots of

nervous system outside the the skull but

in any case for can I interrupt for a

second yes please so I think you're

right that there's an understanding

about the network effect but I think

that as much as I love mainstream

medicine and I trained in it and I so

grateful for my education I still think

it is a silo based

way of taking care of patients so even

if there's an understanding of the

network effect more at the science level

or as you described in Neuroscience

there's still you know if you are a

woman who has constipation

fatigue um maybe an autoimmune

condition uh feel stressed out all the

time feel like your hormones are out of

whack you get sent to the

gastroenterologist for the constipation

you get sent to the room dermatologist

for your autoimmune issues you maybe get

sent to an endocrinologist if you've got

thyroid problems and there's very little

collaboration between these groups so

even though there's an understanding of

the network

effect in real life it's not

happening let's um let's go deeper down

that path because I you point out

something really important and and

you've mentioned constipation a few

times can we view constipation as a

serious enough symptom that it warrants

an immediate intervention that is does

it flag or

signal problems that are severe enough

that that should be the issue that's

dealt with uh for anybody that's

experiencing it and I mean sort of an

odd topic for many people because they

think oh you know bowel movements and

sort of you know there's that kind of um

pre-adolescent humor around this but I

think it's it's so important what you're

what I'm hearing you say is that

constipation is far more common in women

and it signals a general set many

problems occurring does that mean that

women should address constipation and if

so what's the best way to address

constipation yeah I love this question

because you're doing can we have a quick

little meta conversation so you're doing

something that I knew you would do which

is you're teaching me something and

you're changing like there's this social

genomics thing happening where you're

changing my thought about this so I just

wanted to acknowledge that thank you

thank you well I think for me you know

when I hear that there's a kind of you

know you're talking about a phenotype

constipation is a phenotype it's one

that people generally don't wear a

t-shirt explaining it to people but that

I'm guessing anything to do with sexual

health um bowel Health Urology people

just don't talk about right um for all

sorts of reasons and those reasons are

probably so obvious that they're not

even worth discussing but because and

also because we won't change them except

by talking about them y so if you say um

women are far more constipated and

that's signaling a larger set of

problems yes then my immediate thought

is well we relieving

constipation um pun uh intended

retroactively um will that assist in a

great number of issues Andor will it get

them down the road of thinking about

those other issues more specifically

like do I need more magnesium or should

I be putting vegetables in my smoothie

you know so I'm curious about

constipation as a Target yeah for

intervention that then opens up a bunch

of other discussions because there are

these certain nodes in the in the mental

health physical health space that when

someone like we talk a lot deliberate

cold exposure do I think it's magic no

but I think that if someone's getting

themselves into a cold shower once a day

it opens up a number of questions about

themselves and reveals a number of

things to themselves like how do I

buffer stress yeah what sorts of levels

of control do I actually have and on and

on so perhaps not the best example but

um some of us hate cold exposure right

which is we have we have like a gene

that makes us stress out like you

wouldn't believe C exposure which I

would argue makes it um very likely that

even 10 seconds of cold exposure gets

you the effect that you want as opposed

to someone who adores cold exposure like

a penguin needs a lot more cold exposure

for it to have the the Adaptive response

anyway that's my way of of guming

through that uh quite you're you're

you're quite correct um so so let's

answer this question constipation issue

yeah so this is how you're changing the

way I think about this so you're asking

okay instead of looking at constipation

as a constellation of symptoms what

about if you just used it on its own

sort of a

um a

key indicator or signal of dysfunction

with pine Network or maybe something

broader and I think that's

right so it makes me think of a few

things it makes me you're also changing

this book that I'm writing on

autoimmunity and Trauma so thank you for

that

so women experience more trauma than men

this is well established if you look at

the ace studies that were done by the

CDC and Kaiser in 1998 we know that men

for the most part middle-aged men have

about

um about 50% of them experience

significant trauma as defined by the ace

questionnaire women are at 60% and

that's pretty durable since 1998 so

women have more they have different

forms of abuse much more likely to have

sexual

abuse they have a different HPA response

than men

men their perceived stress tends to be

higher and I'm generalizing for a

population so I note you know in

Precision medicine we don't do that we

do medicine for the indiv individual not

the population not medicine for the

average and so if you look at the

physiology of a

female I think that um constipation and

that need to like control and restrain

and hold things

in you know tighten the anal sphincter I

think that's part of the physiology so

I'm veering away from the science but I

do think that it is a really important

signal to pay a lot of attention to now

you also asked about microbiome testing

should we do that or do you yeah well I

have one I have a couple more questions

about constipation I never thought I'd

ask this many questions about

constipation but now I'm fascinated by

the way also this morning I taught

medical students at Stanford about the

fact that we are basically a series of

tubes so you talked about the the anal

sphincter we are a set of sphincters

from one end to the other I mean we are

tubes nervous system being one of those

tubes and and I think in eastern

medicine they talk about the various

locks between those tubes and Chambers

and it's not without coincidence there's

some real wisdom there of course wait

did you just talk about energetic

Anatomy uh more or less I didn't say the

word chakras but uh I might in passing

it's the bondas the bondas right are the

are the are the the the sphincters right

yes that's right uh thank you for for

that the um so what defines constipation

I mean in other words let's let's think

about that healthy rather than thinking

about the unhealthy let's how many bowel

movements should um a woman or a man

have per day assuming this is where it

gets tricky because some people are

doing time restricted feeding some

people are eating more some people

eating more fiber more bulk larger meal

at the end of the day larger at the

beginning of the day we will never um be

able to sort out all those variables but

on

average um how many bowel movements and

is timing during the day for bowel

movements at all uh informative well

works for you um well when I'm asleep um

generally I don't want a bowel movement

so I'm going to be like most people

right well sleep is primary for you

right exactly um I'm I always assumed

that morning time was a was a healthy

time for B movements um and I think

almost everybody babies included

recognize the feeling of being lighter

and more energetic when they've

evacuated their colon totally um in fact

so much so that I'm I'm obsessed with

jungian and fian psychology that the

first thing we learn when we come into

this world right is that we want

something we we feel some sort of

autonomic arousal stress whether or not

it's food or warmth or the need to have

a bowel movement one of the first things

that parents learn is how to recognize

that not by the odor coming from the

diaper but by the look on the baby's

face or their agitation agitation

signals the need for some sort of relief

right temperature relief food relief um

evacuating the bowel relief so my

understanding is that as autonomic

arousal increases in the early part of

the day ideally after a good night's

sleep that bowel movements become more

likely unless that arousal becomes so

great that then people feel so quote

unquote locked up right um because of

the the balance of the autonomic uh

features so early day I'm guessing and

again in the second half of the day and

here I'm totally guessing um and

certainly not having to wake in the

middle of the night um yeah those are my

best guesses that's great so I would

agree with that when I was at Harvard

Medical School in UCSF or residency I

was taught that constipation is having a

bell movement less frequently than one

every once every three

days sorry I don't think I've ever

laughed out loud on this podcast as a

consequence of of uh textbook medical

knowledge are you kidding me is that

ridiculous well that sounds like and and

here pun intended that sounds like the

uh the conclusion of some very um cons

emotionally and and and and in other

ways con ated individuals and again this

might seem like an odd conversation but

the the discussion around constipation

is is present in psychological

literature yes because of this

relationship to the autonomic system

well it's a metaphor in literature it's

crucial so you you spoke to a number of

different threads that I think are

important here so that's the definition

that I learned and I was I heard that

and I was like hell no that doesn't work

for me doesn't work for anyone I

know and I spent a lot of time time

especially in medical school and in my

internship where you rotate on medicine

disimpacting women like older women who

come in who haven't had a bowel movement

in a month whoa and that let me tell you

that is not nice for anybody well

believe me I I became a scientist and

not a physician for a number of reasons

that's one both positive and negative

that's one of them yeah so my definition

of constipation as a western mostly

White girl is that if you're not having

a bowel movement every single morning

and you have a feeling of complete

evacuation anything less than that is

constipation so that's how I Define it

if you're in India and you're eating

food that's got a fair amount of

microbes in it it's less you know

sanitary I'm using that word um as

carefully as I can generally they have

about movement after every meal but

they've got a different microbiome

they're exposed to different microbes

here in the US I would say one

day you also spoke to something very

important which is the balance between

the parasympathetic nervous system rest

and digest and poop versus the

sympathetic nervous system kind of the

on button you know fight flight freeze

spawn so I think for those of us who've

got

issues with autonomic

balance it can lead to constipation and

I like that constipation could be pulled

out and kind of RIT larger as an

important signal what sorts of tools do

you recommend people use to um relieve

constipation um in eating more fiber

sounds like reducing stress is going to

be a huge one yes what are your favorite

stress reduction tools um I like to

divide these into um realtime tools so

big proponent of like physiological s

real time you know these sorts of things

but um things that can really lower the

Baseline on stress overall to facilitate

constipation and other other um broad

indicators of

health so I'm not a fan of lowering

stress I'm a fan of lowering perceived

stress and I think the distinction is

really important

I learned when I was in my

30s

that I was a massive stress case and I

didn't know it it was just sort of I

think I through residency through

working 120 hours a week I just was so

accustomed and sort of um that was 120

not under 20 folks yeah not unusual in

in medicine well they they've changed

training so that you work no more than

80 hours a week now but that was before

my time

so I

became accustomed to a massive amount of

cortisol

massive and I would say I've spent the

past 20 years really working on

perceived stress to find I think all of

us need an all a cart menu of what is

most

effective so what works for me now at my

age is different than you know the the

TM I did as a college student trans

Dental meditation it's different than

the I became a certified yoga teacher

when I was in my 30s that is very

effective for a lot of people it wasn't

enough for my

Matrix I do holotropic breath

work um I didn't read it but I saw that

she just had a paper in cell on your

sign and um it kind of it made me think

like teach me how to sigh teach teach me

how to sigh like can you say a little

bit about that like how do you do it

yeah very briefly that study was we we

wanted to find a minimal effective dose

intervention yeah I just wanted yeah so

five minutes a day we need to figure out

what people would do every day yeah and

we were monitoring subjective mood Etc

but also Biometrics remotely so it's

kind of a nice study which Biometrics

HRV HRV uh nighttime sleep cortisol uh I

wish um so this was done during the

pandemic more than 100 subjects the

advantage was that we got data 24 hours

a day because they're pinging us in

their data uh wearing 24 yeah nice so

that was nice resting heart rate um

subjective mood we would get in touch

with them daily so when people were

swapped between groups like any good

study but five minutes a day of sort of

standard if you will forgive me

meditations so just sitting no

instructions about how to breathe just

focusing on um closing their eyes and

focusing on focusing yep um another

group did box breathing y inhale hold

exhale hold for equal durations the

duration of each of those inhales and

holds was set by their carbon dioxide

tolerance so somewhere between 3 and 8

seconds depending on how well they

regulate carbon dioxide another group

did cyclic sighing so this would be

double inhale through the nose so big

inhale through the

nose followed by it to lungs empty

exhale that second inhale after the

first big lung inhale through the nose

is really important because it makes

sure that all the collapsed avoli the

lungs totally snap open and then the

exhale you offload a lot of carbon

dioxide that's very similar to

holotropic breath work not yes not not

um not unlike holotropic breath work

little bit pranayama is um but the

exhale is rather passive as opposed to

active um and then the fourth category

was cyclic hyperventilation which is a

lot like Tumo AKA Wim hofish breathing

different than Wim Hoff breathing so

this would be so very active inhales and

exhales every 25 Cycles of inhale exhale

that would be one cycle long exhale hold

lungs empty 15 to 30 seconds then repeat

for about five minutes everyone did that

for five minutes and what we found was

that the cyclic sighing led to the

greatest improvements in mood Around the

Clock not just around the the practice

or during the practice as well as

lowered resting heart rate improvements

in sleep Etc and you got to publish in

cell we were very fortunate I I think um

the the

thankfully the reviewers and editors

understood that these minimal

intervention things uh hopefully are

going to be of use to people so so

useful to people I mean how often do you

read a paper like that that could offer

a behavior

change that is so easy to implement I

mean I love that question thank you so

what about did you tell them not to

drink because alcohol has such a huge

effect on H yeah so in this case we

didn't tell them to alter anything else

about their behavior hoping it

background kind of across the same Al

yes and some were Stanford students

others were from the general population

any Frat Boys we drinking heavily

probably not well during the pandemic I

think alcohol intake went way way up

across the board um I mean is an if I

had a magic wand I would I would ask

that people either not drink or drink

two drinks per week maximum at least

that's my understanding of the

literature um are you familiar with the

whoop data with alcohol no but we have a

collaboration with whoop through that

paper um and it certainly disrupts

patterns of nighttime sleep in

particular my understanding that first

phase of sleep that's related to the

massive growth hormone release that you

we all really need and want in their

measure growth hormone we did not no the

second iteration of the study will

certainly include free cortisol by

saliva hormone panels well I'm beginning

to think that we should also um be

asking people how often they're going to

the bathroom in what time of day yes I

mean this thing around constipation is

uh is super interesting and I think that

plus um BL blood markers and then I'm

I'm very excited to learn that um that

urine contains additional markers that

could be informative so yeah it was a it

was a fun study uh not easy study to do

with that number of of subjects um takes

a lot of training for your research

assistance yeah it was a big group it

was nine people in our group and three

clinicians and a lot of lot of phone

calls and a lot of back and forth but

you know and thank you to the subjects

who served as the uh the real life

guinea pigs so yeah I think that stress

you know people's I think people are

starting to appreciate that there are

ways that they can relieve their stress

that that don't all only fall under the

categories of vacation right and

meditation but I want to say that

meditation is obviously a wonderful tool

um it's just it's a it's a tool not

unlike any other tool that is great for

some people and less great for others

well certainly it's a great tool and

it's got such a scientific basis behind

it but there's so many things on this

allart menu sex

orgasm um connect ction feeling heard

and seen and

loved um yeah let's talk about that you

know you mentioned earlier that all

these stress factors you you said

patriarchy right but I think what if I

may um at risk of uh of just

strengthening that uh statement I I mean

that that to me it's is signaling a

bunch of other factors around as you

said like keeping keeping things in

um what do you think

explains let's talk about that because I

think that that's likely to have raised

a certain flag in people's minds like

what exactly is she talking about are

you talking about less opportunity are

you talking about less opportunity to um

to vocalize are you talking about less

opportunity to vocalize and be heard I

mean I realize that there are an

infinite number of variables but given

that it sounds like a a really strong

input to the system uh what I mean by

that is that psychology is influencing

biology and you're saying that that

these uh that these po power

Dynamics structures and Dynamics are

impacting I'd love let's hear your

thoughts on that because uh I I hate to

let a flag like that go by without

fleshing it out and let never waste a

good flag well and let's preface it by

by just saying that like people will

have different opinions on this and

that's and I think that's healthy and

and like with the discussion about

constipation let's talk about what

people aren't willing to talk about when

it comes to health love it so we might

need to talk about patriarchy on part

two but I'll give you some material that

I've been working with

I started I did not even understand the

existence of patriarchy until I was a

bio-engineering undergraduate at MIT I

should mention which has always had a

bit of a of a male um a skewed male in

terms of faulty numbers well my my

that's true at most universities true

well my postto adviser was the late Ben

Baris who was a female toale transition

transgender first transgender member of

the National Academy of Sciences one of

my closest friends unfortunately died of

of pancreatic cancer we were very very

close they're actually making a

documentary about Ben but Ben this is

interesting Ben went to MIT because he

wanted to be around a lot of men yeah

that's a lesser known fact but then he

was a very strong advocate for women he

went as Barbara when he was Barbara and

um by the way he's given me permission

to share all this prior to his death I

recorded a lot of conversations with Ben

um I only ever knew him as Ben by the

way but when he was at MIT he was

identified female and he later talked

about the

intense um suppression oppression

literally is how he described it um

especially given that he was performing

so well yes so you just defined

patriarchy you did it

yourself a couple

things when I was in

bioengineering I took a women's studies

class and it was all about teaching

under graduates about the existence of

patriarchy which I would Define maybe at

its simplest as power

over I'm not saying men are patriarchy

I'm saying something very different

which is power

over let me correct one thing that you

said I didn't go to MIT as an

undergraduate so I'm from I was in

Alaska and I went to the University of

Washington for bioengineering in Seattle

in Seattle okay I dropped out of a

graduate program in bioengineering to go

to the Harvard

MIT program for Health Sciences and

technology in Boston thanks for that

clarification University of Washington

also wonderful place I have many many

many many many wonderful close

colleagues there it's an incredible

place especially for vision science it's

especially good for engineering

bioengineering but um yeah so my my MD

is jointly between MIT and Harvard

and it's the oldest maybe largest

although Harvard says this a lot program

for biomedical engineers and uh MD phds

physician scientist training program

great thanks for that clarification I'm

going to blame the internet for this one

I am I think we need to send our our

Wikipedia editors out I I think LinkedIn

is correct okay great well w wikipedia

uh editors note get out there and make

the make the correction now you you

heard it um so stress that is what

you're really talking about is systemic

stress in the body as a concept as a

consequence excuse me of systemic stress

of environment that's right but there's

you know there's particular forms of it

I would say this also relates to White

Privilege it relates

to uh

racism and when you look at you know

kind of the way that systems including

my beloved MIT

the way that they're set up is that

might Mak makes right and generally the

people that are the strongest you know

big men strong men they're the ones who

tend to be the most successful so for

people who are bipo for people who don't

have white privilege for women it's a

different experience and so I'm using

patriarchy as kind of a umbrella here

but it connects to many other things I'd

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docomond to get 20% off I want to use

this as an opportunity to a keep this in

mind as we turn to a question that I

didn't uh close the hatch on earlier and

it's my fault which is I'm now clear on

the fact that a woman in her late teens

early 20s ought to know something about

her testosterone estrogen thyroid

cortisol

levels should start at least thinking

about her microbiome should be thinking

about how how many bowel movements and

the timing of those bowel movements per

day really and I'm assuming that what I

just described is also true for women in

their 20s 30s 40s 50s on up to hundreds

is that correct that's correct but I

would say that there

[Music]

are differential

opportunities by

decade so I'm glad she circled it back

to teenagers and testosterone because I

think if you know for instance in your

teenage years that you have high

androgens and that you've got this

potential phenotype way into the future

that you may not even notice I mean

maybe you notice you've got a few extra

hairs on your chin or something if you

know that your testosterone is elevated

or some other Androgen it might change

the Arc of how you take care of yourself

so I think that could be very helpful in

your teenage years in your 20s for

people who are a stress case like me so

age 27 on the words at

UCSF if I had known that I was such a

high cortisol

person I think I would have done things

differently I would have changed my

behavior and I don't know because I

didn't base case these

but your

testosterone can decline starting in

your 20s kind of depending on how much

stress your Matrix is under so for women

that can start as early as 28 usually

you're testosterone declines by about 1%

per year what level of testosterone do

you like to see in a woman once she's

sort of post let's say after age 25 what

kind of range is healthy I know what the

reference range is only because I know

one could look it up I don't know it off

the top of my head admittedly but what

what's a kind of a nice reference point

there so the way I tend to describe this

on podcast is the top half of the normal

range great so that I think is a good

benchmark

you know for

PCOS generally it's much higher than

that you know I've seen patients with

PCOS where their total testosterone is

100 to 200 do they always have

peripheral manifestations of that a

little bit of hair the the skin plaques

I've heard about you know so dark and

skin plaque regular periods regular

periods is that um you know I I get a

lot of questions about PCOS yeah um and

you're the first person we've had on

this podcast that's really qualified to

talk about PCOS in a real way um so here

we're talking about too many androgens

cysts on the ovary irregular ovarian me

uh excuse me I keep saying that

ovulatory menstrual

cycle

um what are some other indicators and do

you recommend that women start taking

Androgen blockers or or I mean how do

seems to be a lot of PCOS out there I'm

hearing about it a lot so glad you asked

about this so PCOS is one of those

really poorly understood conditions that

gets it kind of flows flies below the

radar until a woman wants to get

pregnant or she's got some other issue

that drives her to a

physician the problem is that it is a

syndrome right so polycystic ovary

syndrome sometimes polycystic ovarian

syndrome and syndromes don't necessarily

fit together into a really clear

diagnostic criteria so in this instance

there are three different criteria that

we look for so cists on the ovaries

having um clinical manifestations of

hyperandrogenism so that could be

heroism acne other things and then

usually irregular periods and the way

that that's defined at least by the uh

latest criteria is having a period every

35 days or less so typical cycle length

28 days 35 days you know you're skipping

a period here and there so those are the

those are the criteria that we use to

diagnose PCOS there are about four

different systems out there in the

literature for diagnosing PCOS which is

where it starts to get confusing so

there's some women who have nosis on

their ovaries but they've got

heroism and they've got irregular

periods could you define ha sism her

sism is increased hair growth usually in

places that you don't want it so for

women it can be you know kind of male

pattern they might notice it on their

breasts on their chest um um and then

there's of course a a familial quality

to that like I was just looking at a

paper last night looking at ises and how

much heroism they have and whether this

is related to CAG repeats on the

Androgen receptor do they get um not

Israelis but um do women who um who

might have PCOS experience um endogenic

alopecia so hair loss that sort of of

the quote unquote male pattern baldness

of course it's Androgen pattern baldness

as opposed to male we're talking about

testosterone DHD related sometimes you

know this is where I'm going to invoke

clinical experience rather than uh what

I've seen in the literature women

definitely can have some androgenic um

alpia I tend to see it later in life but

this is an important point because we

think of PCOS as you know I was just

talking about it in teenage years like

wouldn't it be nice to know that you

have this phenotype and you're at risk

for all the things that people are at

risk for and we haven't talked about

glucose and ins yet we

should what we know is that pcus is not

just a problem in terms of irregular

periods and then difficulty getting

pregnant so those are mostly problems in

your 20s 30s early 40s but it is a

massive risk factor for cardom metabolic

disease as you get older so many people

tend to pigeon hole PCS is a problem of

reproductive age we have to be thinking

of it over the entire female

life cycle and I would say it's even

more important to consider it over the

age of 50 you know average age of

menopause is 51 to 52 because we know

that that elevated testosterone the high

androgens are probably the greatest

cardio metabolic driver of disease for

women with PCS wow now one other thing I

want to mention and I still have my

notes that we're going to talk about

microbiome testing because that's such a

fun subject

what I was taught to do again saying

this with so much love for the people

who have taught me how to do medicine

what I was taught to do is that if you

have a woman with PCOS you make the

diagnosis you measure her testosterone

you see if she has acne blah blah

blah you asked that woman one

question do you want to get pregnant or

not so then you have these women with

PCS who get started on a birth control

pill if they don't want to get pregnant

if they want get pregnant then you help

them get pregnant by addressing some of

these PCS issues like maybe you give

them Clomid or you do something to make

them ovulate more

frequently that is the way that most

conventional medicine approaches this

and it does women at gigantic disservice

so one of the things I'm speaking into

is the gender gap that exists so I my

feeling is that the research money that

goes into women's health is abysmal

compared to what goes into Men's Health

really and I think that's changing but

there's also a huge lack of awareness of

sex and gender differences when it comes

to the way that we

construct clinical trials and other

experiments well that's absolutely true

I mean I sit on I've sat on NIH review

panels for more than a decade now I'm a

regular standing member which is only to

say that I see the research as it's

being proposed yes and now it's required

no Grant will get funded without sex as

a biological variable and here I'm I'm

by the way folks this is sex biological

sex the noun not sex the verb both are

super interesting obviously but um when

we say sex as a biological variable

meaning even even if it's a study on

mice where did that start though that

didn't start that long ago it must have

been I think we can thank I don't want

to misattribute here I think we can

thank Francis Collins for insisting on

this amen Francis and Bernardine hey

Bernardine Healey has done so much to

help us but you know she made the

Women's Health Initiative which I hope

we'll get to which just a hot mess like

so confusing the data that came out of

that and these trials are long and so

the data are only now starting to emerge

so just to be clear I mean I have a a

question that I don't think is going to

take us off track but this is I'm going

to posee this question as a hypothesis

because I think it's likely to be uh a

little bit of a of a not a barbed wire

question but maybe like a prickly

question when people first hear it but

it's posed as a hypothesis you you

mentioned some of the psychosocial

stress issues based on at the organiz

ational level institutional level

societal level maybe right down to the

family and and just life that are

biasing Health outcomes for the worse in

female populations okay you refer to as

the patriarchy I'm just trying to put

make sure that we're both talking about

the same thing and that's non-exhaustive

I realize that's just a subset of the

issues I'm also hearing there's a lot

more

PCOS which is hyper

androgenization of the ovary in there

we're talking about

you mentioned you know excess

testosterone which females naturally

have more testosterone than they do

estrogen anyway but we're talking about

elevated

levels here's a

hypothesis one hypothesis would be that

the increased androgens and the P PCOS

are a consequence of the psychosocial

conditions that are I don't want to say

forcing but are biasing the need for

females to um think behav react act in

certain ways to survive let alone Thrive

is that a I don't say this for any kind

of political correctness hypothesis this

is a in my this would be a fun

interesting and I think important study

to run right depending on stress and the

conditions the specific type of stress

do females underproduce or overproduce

androgens or is it a neutral effect does

that make make sense

I love this question so let me just

paraphrase the last part of it to make

sure I got it it sounds like what you're

asking

is could PCOS or at least some

phenotypes of PCOS be a response to what

I'm calling

patriarchy and then you had a second

part to it which is do healthy women

like what is their production of

testosterone like is that right yes and

and with the acknowledgement I mean

you're the expert here um you're the

physician clinician and expert in

hormones and I'm not but with the

understanding that absolute levels of

hormones are interesting but perhaps not

as interesting as the ratios of

testosterone to estrogen so when we're

talking about excess testosterone we're

really not talking about oh women making

a lot of testosterone because frankly

they already make a lot like then most

people weren't aware of that I wasn't

aware that women make more testosterone

than estrogen right and so it's not

saying that testosterone in women is bad

or is always a reaction to the

environment yes but when it becomes

um super physiological or hyper elevated

is I could imagine all sorts of social

conditions that would create that um so

in males and females but here we're

talking about PCOS and females in

particular so I'd love for you to

speculate um should we run the study we

should totally run the study

because I don't know the

answer I suspect that you're on to

something it may not explain all of the

women with PCOS because as I metion

there's a lot of different phenotypes

but I think it could

explain a significant

portion and you know you're almost

you're saying if we look at the gene

environment interface this environmental

influence of having being someone who's

got power over you if if pcus was a

response to

that the way that we treat it would be

completely

different so on the one hand I want to

be careful not to dismiss the suffering

and experience of women with PCOS I've

got a lot of women with PCOS in my

family and it

is there's so much pain and suffering

you know especially if you want to have

a baby and you try for years and you

just can't

ovulate on the other

hand I read a paper recently and maybe

we could site this that compares the

phenotype of a woman with pcus

to a man who is

hypoandrogenic and I think that's a

really interesting way to look at this

because the thread we haven't talked

about with PCOS is the the role of

insulin and

glucose so for some of the phenotypes of

PCOS the problem is hyper insulin emia

High insulin in the blood is driving

those Thea cells in the ovaries to

overproduce testosterone these women are

insulin sensitive so more insulin is

being cranked out and the cells in the

ovary are therefore making more Androgen

you don't like to say insulin resistant

oh I I can uh I don't have a problem

saying resistance like the way I'm just

I'm just a little bit outside the lane

lines of my expertise so I I was trying

to use it what what is the correct gnom

en clature so that we can make sure

everyone well what I like about insulin

insensitive the way that you just said

it is that I think that offers people a

way in and I love to do that in terms of

messaging insulin resistance starts to

lose people cuz they don't really get

what that means at a receptor level I

think I say insulin insensitive because

when people hear insulin sensitive it

almost sounds like a bad thing but

that's actually what you want so I think

I think that's how I defaulted to

insulin insens what your insulin I don't

know what I'm do for a blood test yes

you are I'm doe for a blood test um I

had blood work done about eight months

um sure that'd be great I I uh I'm

always um experimenting with different

supplements and different behavioral

regimens and I've kept charts since I

was 19 oh like my patient I been sort of

Obsessed by this and I would say

everybody if you can afford it and at

the time actually I had to save up

Insurance wouldn't cover it um get some

basic blood work done so that you have a

reference point do it as soon as

possible because even you know the we've

been talking about these women over the

life

cycle I wish I knew what my insulin was

when I was a teenager I wish I wish I

knew what my fasting insulin was I

really wish I knew my postprandial

insulin like in my teenage years in my

20s in my 30s well I knew it in my 30s

starting at 35 are you a fan of

continuous glucose monitors the hugest

most gigantic fan of cgms I've never

seen any tool that I've ever used in

medicine change Behavior the way that

cgms do wow why do you think they are so

effective at changing Behavior I've

tried one and I really liked it I

learned that in the sauna my insulin or

my blood glucose goes up probably by a

bit of dehydration I learn what kind of

foods work for me which don't

um I I thought it was fascinating I

learned how every Behavior you could

possibly imagine use your imagination

impacts blood glucose totally

fascinating to me including how a two

wake wake-ups during the middle of the

night versus one versus none impacted

blood glucose the next morning

fascinating for a data junkie like me it

was like I was in heaven um why do you

think they are so effective in changing

behavior is it because of that that

people can see that real time control

like scan in and like oh that's the

that's the sandwich I think it's many

things I think

it's generally the Enchantment of

learning about your own chemistry and I

love that and I think for me what I've

seen you know I feel like doctors are

basically

marketers like the sacred marketing like

our job as a physician is to convince

people to do something that we think is

good for them based on the best

science but we can't just say here why

don't you fill this prescription for a

CGM you have to Market it you have to

say I think this completely changes the

way that you approach your pre-diabetes

I think this could dramatically affect

your risk of Alzheimer's disease that

you're so worried about that your mother

has so our job as Physicians is to be

that sacred marketer so cgms are one of

my tools that I think are so crucial so

enchantment number two yeah it's the

real- time effect so if you go get your

glucose and Insulin measured or maybe

you do like a 2hour glucose challenge

test where you look at glucose and

Insulin at the fasting Point 1 hour

later 2 hours later or more frequently

that does not have the same kind of

behavior effect as having continuous

data where you can say okay I drove to

see you Andrew from my place in Berkeley

and it was stressful it was torrentially

raining and I know my glucose was

elevated like I think really

understanding what the the mediators are

of your glucose control is essential now

that said it's also kind of a later

effect I mean I'd rather know your

insulin and we know from uh the white

head White Hall study that insulin

especially postprandial insulin fasting

insulin too can change years and years

before you get a change in glucose so um

that's more for pre-diabetes and

diabetes so I think those are the main

reasons why I think it's such an

important tool

third thing is it democratizes

data which you do too I mean incredible

how you do that with your podcast but I

think one of the most hopeful and

exciting things that I'm seeing right

now in the health space is that we're

going from this patriarchal relationship

where doctors hold the power and are The

Gatekeepers of data to patients and

clients having having much more access

to that enchantment about their own

chemistry and their own biology so to me

that is so exciting like for me to be

able to I've got you know probably 100

patients that are in a data stream with

me where we're looking at their glucose

and I can I mean I'm on spaical so I'm

not doing this so much anymore but I can

call a patient be like why is your

glucose so high like what did you do oh

it was my birthday I had a piece of

birthday cake like that kind of

collaboration that also is teaching the

patient to be their own clinician to me

that is a loop of benevolence and

integrity that I think is essential to

creating Health we've got a disease care

system we need the democratization of

data to become a health-based

system Amen to that a million times over

we share that uh sentiment can tell it

at a deep level I I think the pandemic

actually assisted in well it harmed many

things but it assisted in people's

understanding that um no magic fery nor

the government nor any anyone was going

to arrive at their door with a kit of

things to make them healthy that provide

sunlight movement sleep and all the

various aspects of nutrition no nothing

nothing that it everyone has to have

access to first and foremost and then

Implement those things as best they can

speaking of which and kind of circling

back to this idea of people in their

late teens 20s 30s and onward if you had

a magic wand and you could give like two

or three

don'ts or to make it personal if you

could go back in time and erase certain

behaviors what would the the don'ts

category be um you can tell us more than

two or three um but if the goal is to

maximize vitality and Longevity and

those are not

always uh parallel to one another

certainly not the same thing sometimes

orthogonal but let's just say

fertility being a proxy for vitality and

Longevity I think people will sometimes

forget this that fertility isn't just

about people who want to conceive

children it's also it's a it can serve

as a proxy for vitality and Longevity so

uh what would you like to see patients

let's focus first on female patients but

um if it extends to male patients as

well what would you like to see them not

do yeah or do far less of I really like

that so I would say a few things I'll

just headline them and then we can go

into detail number one sleep I do want

to diverge from you a little bit on some

things but sleep is probably not one of

them oh well feel free I mean you're the

one that worked 100 you're the one that

worked 120 hours a week sleeping much

then's I can't imagine unless unless you

lived in a different reality than I do

um uh you and there are times in my

career where I was pulling all nighters

and sleep deprived there just it I don't

recommend it but I did it hope you don't

do that anymore no longer if I can avoid

it but there were years many years where

it was like all right here we go and I

I'm quite um Adept at it for one cycle

yeah but two nights I kind of start to

fall fall apart totally yeah so I would

say sleep alcohol High perceived stress

and I'd love to talk about maybe um the

data on telr and what we know so you'd

like to see people get enough sleep so

don't don't just yeah not all of these

are concordant so um not enough sleep

too much alcohol too much perceived

stress eating the wrong

Foods toxic

relationships and isolation and then

number

six

um not moving enough or not moving and

exercising in a way that really fits

with your

body we start with that one actually cuz

it's such a and then work backward um uh

that's interesting I I I think nowadays

people appreciate the need for quote

unquote cardio I know that the the

exercise physiologists cringe and and

dissolve into a puddle of Tears when I

say that but getting the heart rate up

over some period of time longer than 10

minutes in order to generate

cardiovascular health circulation so and

resistance training of some kind maybe

flexibility what what do you mean by

Body phenotype or and exercise I'll

speak from personal experience so what I

did through I mean I gave up my 20s to

medicine and during that time I

occasionally got to the gym you know at

UCSF on pralis you could go to the gym

and then as soon as your beer went off

you're back into the hospital but I

didn't exercise much I had um do you

remember Nordic tracks I had a Nordic

Track in my house and that was that was

like it what I believe because for me

the primary outcome that I'm interested

in is cardiometabolic health so when it

comes to exercise what I really feel if

we're going to be at a population

level I feel that about a third cardio

2/3 resistance training is based on my

synthesis of the literature the best

combination and I think there's you know

as you described with your

s um study I think there's a minimal

effective dose which for a population is

about 150 minutes I think most of us

need a lot more than that per per week

per week but I think you know for me

because I have a

phenotype

that produces a lot of insulin kind of

depending on how I'm on my game I have a

lot of glucose so I have to exercise a

lot more to dispose that glucose so I

think you then have to move from

medicine for the population or

prescriptions for the population to

what works for the

individual I think that recommendation

is fantastic um I think resistance

training well let me put it this way I'm

neither a trainer nor a physician but

I've seen in family members that were

doing I wouldn't say a lot of cardio but

just cardio that when they add

resistance training everything in terms

including their

biomarkers um have improved dramatically

yes is in particular for female members

of my family well one of the one of the

mediators that I think is important

especially for people who do what I call

chronic cardio which is what I

did is cortisol so we know that um

Runners especially marathon runners

people who do a lot of cardio and don't

do much resistance training they tend to

have much High cortisol levels and you

can buffer that with vitamin C vitamin C

can decrease the effect but chronic

cardio doesn't always serve people so

quick personal example when I first

started measuring hor panels in myself I

went to my physician and I said I'm 35

I've had one kid I want to have another

kid I've never been so exhausted in my

life I just feel like I'm pushing a rock

up the hill I've got this belly fat that

I don't like and um I don't want to have

sex with my husband so what do you think

what could we do about this and he

offered a birth control pill and an

anti-depressant oh goodness so I left

him and I went to the lab and I ran a

hormone panel and my cortisol was three

times what it should have been my

insulin was in the 20s I was fasting my

glucose was

105 my thyroid was mildly abnormal my

progesterone was low and that set me on

this course of realizing that what I was

doing as physician taking care

especially of women was not getting to

some of these root causes that are so

essential and I would say I had to start

first with

cortisol at that time I was running four

miles three times a week four times a

week that was just Rising my cortisol

further so that was not the right

exercise for me I needed more adaptive

exercise I started doing Pilates more

yoga that helped to lower my cortisol I

mean it started me on you know changing

the way I was managing perceived stress

and it also changed my supplement

regimen could we talk about that um what

the moment you said lowering cortisol

thought of the two supplements that come

to mind are ashwagandha which I think

can potently reduce cortisol but I've

heard some recommendations about cycling

it um and I've always wondered about

time of day for ashwaganda intake

because sort of quote unquote want

cortisol elevated in the early part of

the day yes and we know this uh we know

you do not want cortisol peaking later

in the day no you do not interferes with

sleep interferes with sleep um and then

the other supplement is riola rosacea do

I am I pronouncing that correctly yeah

so riola is very effective it's been

shown in multiple randomized trials to

lower cortisol so that could be very

effective what sort of dose I've started

taking it recently by the way and I made

a huge mistake I like to make the

mistakes first so then my audiences

don't make them um as I was taking it I

heard it was an adaptogen so I thought

oh I'll take it before resistance

training but of course you want the

cortisol Peak during resistance training

because that's going to set in motion

the Adaptive response so I started

taking it later in the day and it's

really improved I would say my late day

second half of the day cognition this is

subjective to be fair I just feel like

I'm in a more even plane of attention in

the second half of the day so you're

describing an NF1 experiment which is

anec data it well it is not anecdotal so

I was taught at Harvard Medical School

that the hierarchy of evidence starts at

the lowest with expert opinion you know

case studies then you've got cohort

studies then you've got um observational

data that's prospective then you have

randomized trial but the highest quality

evidence of all is the n of one

experiment where you serve as your own

control so what you're describing with

riola I would frame that as n of one

experiment where you have a wash out

period and you compare before and after

and I'd like to measure some other

metrics to see if there's an effect

including your cortisol so rodial has

been shown in multiple randomized trials

to reduce

cortisol the other thing that I think is

super effective is phosph title searing

PS for short fish oil also more modestly

reduces

cortisol ashwaganda is interesting so in

my first book the hormone

cure which I read by the way you did I

did I was hoping that was the one you

read I did I read it and it's

spectacular and I thought going into it

I had this like you know let's just call

it what it was it's kind of male bias

like is there going to be anything in

here for me because uh I'm I don't have

ovaries and you know is this going to be

and it was IM mely informative um so

thank you yeah I have very fond

Recollections of the the walks I took

listening to it and then I own the print

version too so I like to switch back and

forth so thank you for that it's a it's

a superb book for anyone to read thank

you I so appreciate that so in chapter 4

you may or may not remember that

ashwagandha at least the time that I

wrote that book ashwag ganda's data is

not great but lack of proof is not proof

against so with ashwag gandha most of

the comes from thousands of years of

using it in itic medicine and it's

considered again not my science hat it's

considered a double adaptogen so that

it's potentially helpful when you are um

a high cortisol phenotype like I was

like I sometimes still am or low

cortisol I haven't found that in my

patients although I'll give you one

exception so ashwaganda is mostly based

on animal studies there's not as much

human data but it is used a ton in

Integrative

Medicine the um there's one supplement

that I found to be incredibly helpful

for people who tend to have high

cortisol at night and that's called a

cortisol manager it's by integrative

Therapeutics I don't have a second um

supplement manufacturer that makes

something similar it's their number one

selling supplement because it's so

effective is it a cocktail of several

things it's a combination of phosph tile

Serene and ashwaganda tell tell me more

about tile Serene I I am familiar with

it for it's been mentioned by some

guests that were on the Tim Ferris

podcast long ago for other reasons I

think related to sleep yes um and maybe

that's another reason why you like it um

but before we move on from Rola is there

a dosage of rodal or rosacea that you um

so I would refer people to my book

because the randomized trials and the

doses that were used are in there so I

can't remember with riola although I

took it this morning to prepare to be

with you yeah we can look it up

remember with phos sering I take that

regularly so 400 to 800 m is the typical

dose for PS and what's interesting is

that in the randomized trials that were

done 400 milligrams was more effective

than 800 milligrams interesting I've

found that for several supplements that

the lower dose was more effective yes um

yeah I won't it doesn't matter what

those were and so when you say PS you

were referring to by the way folks not

PCOS just cuz scien and clinicians are

familiar with and Military very familiar

with acronyms phospha tidal serin PS so

400 800 milligram 400 being more

effective taken later in the day or

early day does it matter it depends on

when your cortisol is high so for me I

tend to you know what's the pattern for

cortisol typically it rises to its peak

30 to 60 minutes after you get up then

it has this gradual kind of asmic

decline until you go to bed so if you're

someone like me who Peaks like way crazy

high I don't do that anymore but that's

what I used to do I need a phosph Serene

in the morning for people who are high

at night who have what's known as a a

flat cortisol pattern or a inverted

pattern you want to take it at night and

the flat pattern just quick sidebar is

that that's associated with a number of

conditions that most mainstream

Physicians don't know about so a flat

pattern where it's in the morning and

it's high at night is associated with

anxiety depression uh decreased survival

from breast cancer that was studied at

Stanford by David Spiegel that he was my

um coll close even collaborator even uh

on the breath work study that we oh

interesting yeah he's our associate

chair of Psychiatry now a wonderful

human being has has been a guest on this

podcast and and I'm now fantasizing

about a conversation that includes uh a

panel of of of uh Incredible Minds like

you and David from the clinical side so

in any case um yeah the late shifted

cortisol not good not good not good and

it seems to have the

worst immune

Downstream issues of any of the cortisol

patterns so that's really important to

know about because it then maps to

things like um it's related to

PTSD so that's the pattern we see like

in vets who've got PTSD as well as

others it maps to autoimmunity it maps

to

fibromyalgia I was told that one in 12

people um have our heterozygous so one

mutant copy or hypermorphic for some

some mutation in adrenal related Gene so

congenital adrenal hyperplasia is that

true and if so that means that one in 12

people walking around are cranking out

far too much cortisol or not enough

cortisol all or the quol system is

already skewed in a direction that makes

life more challenging at the levels

we're talking about um did I hear that

correctly because that one in 12 is not

a small number it's not a small number

it fits with what I see clinically I

mean I want to see that data just to see

um what does that mean and could you

modulate it with environmental

influences but it certainly fits with

what I see you know I was taught once

again in mainstream medicine that in

terms of adrenal function

it's very binary how most clinicians

think about it you either have Addison's

disease and you don't make enough

cortisol or you've got Cushings or

cushingoid pattern and you make too much

cortisol and anything in the middle is

normal and my experience is that hell no

like there are those of us like me who

make a lot of cortisol I don't have

Cushings maybe I've got one of these I

wouldn't call it a mutant Gene I would

call it more of a um

vulnerable Gene so maybe I have one of

those maybe that's part of the reason

why I make you know two to three times

what I should be I'm aware of certain

groups of individuals from within the

military sector that um have there's a

more frequent occurrence

of some mutation in C C congenital

adrenal hypertension not necessarily two

copies which will if people look that up

they're going to go oh wow there's all

these phenotypes and um but sort of

hypomorphic type thing so you know less

than or too much cortisol and they are

very good at staying up multiple days

per night right uh multiple nights in

series so they can pull all nighters

very easily they can push harder when

most people would quit and everyone

thinks well that's a great phenotype to

have but guess what it's because they

hyper produce cortisol yep and um so

that's interesting and I think if we

were to panel medical students and

graduate students and you were to look

at you know who's pulling excessive long

hours who's stressed out a lot even

outside of Academia and medicine and

pushing pushing pushing really hard I

think the ability to push and not crash

we think of it as adaptive but in some

sense it's maladaptive over a series of

years which is sort what were you

described earlier yeah it's such a good

point

because you know you in some ways you'd

want to select for that in certain

professions like in the military like in

medicine

um but I would wonder for those folks

about the downstream consequences of

producing so much cortisol no it's got

to be detrimental for their health in

the long run and and you see that but

even the data shows that if you're

someone like me who makes a lot of

cortisol higher rates of depression like

50% of people with major depression have

high cortisol levels higher rates of

suicide um much more metabolic

dysfunction we know that trauma as an

example maps to an increased risk of

glucose metabolism issues and certainly

High cortisol does that because it's one

of the jobs of cortisol is to manage

glucose and

it's it kind of sets you up for um this

one number five which is toxic

relationships you know someone who hyper

produces cortisol it's hard to live with

someone like that it's also I would say

people that have this um let's just call

it biological resilience um it's not

always adaptive because you can stay in

in bad circumstances longer the ability

to to crash provided it's not suicide or

life life destroying or you know long

Arc of of of pause and the requirement

to you know take two years off from work

or school or something um the ability to

keep pressing on is is a double-edged

sword let's put it that way um I want to

make sure in staying within this

conversation uh because you mentioned

fos serin we talked about Rola Rosa as

we talked a bit about ashwagandha you've

also talked about Omega-3s and fish oil

in particular I'd love to know your

favorite sources of these I think

nowadays there's more General acceptance

that getting these essential fatty acids

is important do you have a threshold

level of sort of grams I I've encouraged

uh um podcast listeners to consider

depending on what they're eating to try

and get a gram of EPA or more per day

does that seem excessive um and what are

the real data on epas because then the

uh cardiovascular experts always hit

back and say oh no you know it's not

good for cardiovascular health and then

you go well it's better than

anti-depressants and other studies and

they go no so I feel like if you really

want to make your life difficult if you

want to raise your cortisol you go on

Twitter and you say something positive

about Omega-3s of fish

oil and um and you learn a lot um what

are your thoughts on Omega-3s I take a

lot of them I've always been a big fan

yeah so this is where I personalize I

think some people need more than others

and what I do is I measure your level so

this gets back to nutritional testing so

for you I would suggest an Omega Quant

or one of my favorite cardom metabolic

panels is to do a Cleveland heart lab so

I think they they give me the most

reliable information not just for lipids

and subclasses and you know NMR

fractionation but it also gives me an

insulin resistance score it gives me um

levels of Omega-3s great we'll provide

links to these different sites so people

but one quick thing about that the whole

story is not Omega-3s in taking fish oil

so the work of Charley Siran at the

Brigham is showing that the way that we

resolve

inflammation our understanding of it is

really I think in the learning to crawl

stage and so if you look at the omega-3

6 pathway in the body fish oils can help

you know kind of push the reactions in a

particular direction but typically

they're not enough for the resolution of

inflammation now what most people do

including my NBA players is they pop an

ibuprofen or something like that when

they've got inflammation that's got lots

of other side effects that are not so

good for you and we know in terms of the

resolution of

inflammation that taking something like

ibuprofen reduces the amplitude of

inflammation by by about 50% but then it

potentially blocks the complete

resolution of inflammation so there's

these new supplements that you may have

heard of called specialized Pro

resolving mediators there's a lot of

different supplement companies that make

them and that combined with fish oil

seems to be the best combination and

what I do for athletes who've got you

know kind of the normal aches and pains

of the training load they have is all

combine a little

aspirin small dose just like um 81 Mig

or two of those baby aspirin together

with fish oil plus specialized Pro

resolving mediators and there's some

that are NSF they're certified for

sports but the the dose I would say with

my patients some of them only need 1,000

milligrams your Gram that you mentioned

for the population some of them need six

gram together with spms so I think it

has to be

personalized how young um

is it okay for people to start taking

Omega-3s um for instance young women in

their teens people in their 20s and

their 30s young guys in their 20s and

30s should they take fish oil if just as

a assuming they're not going to get

anything tested I'm thinking about the

college student who is really into

biomarkers and that sort of thing we'll

go do some of this

um but many people won't but they want

to do the right thing so they'll try and

drink a little less hopefully hopefully

they won't smoke or vape please please

don't smoke or vape the idea that vaping

is okay it's like we had a whole episode

so bad so bad for everything we're

talking about let's end that chap

exactly so just you know avoid they

hopefully they'll try and avoid those

things hopefully they'll avoid hard

drugs um hopefully they'll avoid getting

any STI if they do they'll resolve them

quickly hopefully yes um so but they

might say oh well okay I'm willing to

you know take some magnesium or take

some phosph sering buffer my cortisol

eat some vegetables um should they

considering fish oil as a kind of a

cross theboard in ulatory thing so I'd

like to rank order these I would say

fish oil yes I think a th milligrams as

a general recommendation is good but I

also have a food first philosophy so my

preference would be that they're having

salmon or some kind of Smash fish and

they're getting that as the primary

source of their Omega-3s and then the

days that they don't have fish I

recommend it probably twice a week that

they take fish oil then I would put

magnesium next since so many people are

deficient then I'd probably put vitamin

D what how many IU a vitamin D per day

well you keep asking me this like for

the the population yeah well for the let

me put it this way for the LA for the

lazy person or and this is an or not an

and um or the person who um just doesn't

have the finances to go get measured

levels measured because you know our

audience is a huge range we've got

people who can have tons of disposable

income that list in the spot we have

people with no disposable income so a

th000 to 2,000 International you but my

you know what I do is I dose to a serum

level that's between about 50 and 90

great and so I have a vitamin D receptor

uh snip and so I need to take about

5,000 a day to get to what I need a lot

of people don't need that and you know

there's some supplements

that I don't know if they need so you

mentioned phosph tile sering for someone

who's a college student and their

cortisol is completely normal they're

wasting their money on PS they don't

need it they might need it later but

they don't need it now I'd like to make

sure that we Circle back to birth

control in particular oral contraceptive

birth

control and we should touch on iuds

perhaps a little bit more but what are

your thoughts on S pure estrogen birth

control this is what I learned when I

was in college is that birth control is

basically tonic estrogen so constantly

taking estrogen estrogen women are

taking estrogen so that they don't get

the estrogen

priming of progesterone you're not

getting any ovulation and I've known

women that have been taking oral Contra

or that took oral contraception as like

estrogen pills basically for 5 10 15

years are there long-term consequences

of this as it relates to pregnancy

PCOS

menopause what if so what are some of

those consequences um what are your

concerns what do you like about oral

contraceptive what do you dislike about

them I like how balanced you asked that

question so women who take oral

contraceptives as long as you're

describing like 10 years or longer we

call those Olympic oral contraceptive

users in terms of benefit I think that

especially when they first came out and

even now it gives women reproductive

choice and That's

essential as you may know our

reproductive Choice has been declining

recently so I'm a big fan in that regard

and we've got a lot of data to show both

the risks and also the benefits of it so

I'll speak first into the benefits

because uh I'm going to get on a soap

box a little bit about the risks so we

know that it reduces the risk of ovarian

cancer so there's something about this

idea of incessant ovulation that is not

good for the female body so if you look

at for instance women

who are

nuns who uh don't take oral

contraceptives and they have a period

every single month of their reproductive

lives they have a greater risk of a

brain cancer so if you look then at

women who have uh several babies and

they've got a period of time when

they're pregnant that they're not

ovulating and then they breastfeed for

some period of time they have a lower

risk of aaring cancer so oral Contra

contraceptives help with reducing

ovulation and reducing risk

we know that if you take the oral

contraceptive for about 5 years it

reduces your risk of ovarian cancer by

50% and that's significant

because we're so poor at diagnosing

ovarian cancer early there's really no

method that's really effective we use

ca125 and ultrasound screening

especially in women who are at greater

genetic risk but even that often we

diagnose it you know in a later stage

maybe just because that statement is

going to highlight for a number of

people um the question of what are some

of the Sy earliest symptoms that people

can recognize without a blood test so is

ovarian cancer is it going to be pain so

the problem is the symptoms are so vague

and they're so

non-specific one of the most common

symptoms is bloating and we've already

talked about constipation we've talked

about how women have this longer track

GI track and so bloating is a really

common experience for most women you can

have bulk symptoms you know feeling like

your your lower belly is kind of pressed

out so the way that

we inform women in terms of watching for

this is to get regular gynecologic exams

um for women who are at high risk where

they have for instance an ultrasound for

some reason it shows a mass that we're

concerned about there's a way to triage

that in terms of what kind of evaluation

that they need and that's a situation

where you might get a blood test called

a

ca129 ca1

25 the um yeah the problem is the

symptoms are so vague it could be it

depends on how big the tumor is how much

bulk you have what it's pressing on so

if if um taking estrogen and thereby

reducing the frequency of ovulation

lowers the risk of ovarian cancer should

women that are even women who are not

sexually active so they're they're not

actively trying to get pregnant or avoid

getting pregnant but if they're not

sexually active then the probability of

conceiving unless they go through some

IUI or some other route is is very low

as far as I know um that's what I was

taught in high school anyway um would

they be wise to suppress ovulation for

periodically using hormone-based

contraception just so that they can

offset the risk of ovarian cancer that's

a very rational question and I would say

that's what mainstream medicine has had

at its back to recommend oral contra

cves not just for women who are seeking

contraception but for acne for painful

periods for really kind of the drop of a

hat they're prescribing oral

contraceptives that's what I was taught

to do but there's so many consequences

and I think the issue here is more about

consent

because in OBGYN and I started out as a

board certified OBGYN and I now mostly

see men but I was taught as an OBGYN to

convince women to go on the oral

contraceptive and I think a lot of that

is pharmaceutical

influence so maybe we could talk about

the risks and why the answer is no to

your question um as we do that could I

just ask is the um the so-called ring

the new it used to be called the NOA

ring maybe that's a brand name but it

when I was in college there was all this

discussion about the ring all right by

both men and women for reasons that

don't belong on the podcast um use your

imagination folks so um is the the ring

obviously it's not oral it's not oral

hormone contraception but it's

hormone-based right the ring is

releasing estrogen locally as opposed to

taking it orally but would you would you

slot it under what you're about to tell

us in terms of the

concerns so we have less data about the

ring so the oral contraceptive is two

hormones it's ethany

estrad and it's a progestin so it's not

the normal uh progesterone that your

body makes your ovaries make and your

adrenals make it is a synthetic form of

progesterone and it is the same

progestin similar same class that was

shown to be dangerous and provocative in

the women's health initiative so I'm not

a fan of

progestins I do not recommend them for

any woman unless the consequence of not

taking them is surgery or some other um

you know unless it it gives them some

freedom in some way so I don't like

progestins the uh Nar ring is estrogen

plus progestin but it's released

transdermally through the vagina so

given the the way that um it's delivered

to the vagina the doses are lower than

what's taken orally but in terms of some

of the risks that I'm about to talk

about we don't know about much of the

data yeah we think that it's similar

there's probably a spectrum of risk and

the ne ring is a little more towards the

middle than you know what I'm talking

about with oral contraceptives okay are

you ready for that yeah I'm ready for

the risks okay so like with almost any

pharmaceutical the oral contraceptive

depletes certain

micronutrients so magnesium there's

certain vitamin BS that are

depleted uh it also affects the

microbiome that data is not as strong

but there seems to be some effect and

there's also an increased risk of

inflammatory bowel disease in autoimmune

condition it increases inflammatory tone

so the studies that I've seen increase

one of the markers of inflammatory tone

High sensitivity CRP by about 2 to

3x it seems to make the hypothalamic

pituitary adrenal axis more rigid so

that you can't kind of roll with the

punches and wax and Wayne in terms of

cortisol production the way that you can

off the birth control

pill it can affect thyroid

function I'm thinking of the slide that

I have that has like 10 problems

associated with oral contraceptive but

that's what I can remember right now

that's very helpful and it makes me

wonder whether or not if on the one hand

oral contraceptives are protective in

women against ovarian cancer but then

they have these other issues yeah

there's one another I want to mention

please anytime you take oral estrogen it

raises sex hormone B globulin and you've

talked to other podcast guests about

this Kyle I think sex hormone binding

globulin I think of as a sponge that

soaks up free estrogen and free

testosterone so when you go on the birth

control bill you raise your sex hormone

binding globuline it soaks up especially

free

testosterone and for some women it's not

a big deal they don't notice much of a

difference but then there's a phenotype

maybe related to CAG repeats on the

Androgen

receptor who are exquisitly sensitive to

that decline in free testosterone so

this then opens the portal of talking a

little bit about testosterone and women

so we've mentioned already that it's the

most abundant biologically the most

abundant hormone in the female system

even though men make almost 10 times as

much or even more than 10 times it is so

important for women it is essential to

so many things not just sex drive and

muscle mass and seeing a response to

resistance training but also confidence

and

agency and so those women who are so

sensitive to their testosterone level

they've got this high sex hormone Bing

globulin their testosterone

declines what they describe is vaginal

dryness maybe a decline in sex drive but

there's also this bigger issue related

to confidence need agency even

risk-taking from studies that we've done

with MBA students that I think is a

serious

problem maybe the most important out of

all of these things is that it can

shrink the clitoris by up to

20% 20% and that includes the a

regression of the of the nerves that

innervate the the clitoris is that I

mean that's a very good question as a

neuroscientist yeah I would think uh

used to teach uh the neural side of of

reproductive Health we need to do a

series on Sexual Health maybe you would

co-host that with me sure

I we could certainly use your expertise

I think um yeah that's a dramatic that's

a dramatic number yeah but then let's go

back to the sacred marketing if I've got

a woman that I think should not be on

the birth control pill maybe she's

taking it for acne or she's taking it

because her periods were a little

painful what I'm going to do is say

let's leverage these other ways of

making your period less painful let's

take the message of your painful periods

and figure out okay is it your

inflammatory tone and we give you some

fish oil and spms maybe a little aspirin

when youve gotch your period like let's

find some other ways to deal with it

than to take the oral contraceptive

which you have not received informed

consent about because it can trick your

by up to 20% now that usually

convinces most people

to the elevation in sex hormone binding

globulin does not seem to go away when

you come off the birth control pill to

me that is the biggest problem problem

with prescribing oral contraceptives now

the data that we have is limited there's

one woman who uh Claudia something

something who looked at sex hormone

binding globulin a year out from

stopping the birth control pill and it

was still elevated it wasn't as high as

it was when they were on the pill but it

was still elevated so your question

about reversibility I don't know if we

know the answer to that wow okay um

that's yeah that's a significant

statement

and something that for

consideration related to this although

this might seem not related it

is how early do you recommend that women

go get their follicle number assessed in

other words to get a size a sense of the

size of the ovarian reserve and their

amh levels U measured um I'm going to

I'm an amateur Outsider as I say this

but we have an episode on infertility

where I just describe the ovulatory

menstrual cycle yeah um and I'm not the

best person to answer that yeah well we

can I'm too far off from it okay well um

I suppose then from taking the

perspective of somebody who thinks about

fertility in terms of at least congruent

with vitality and Longevity would given

that it's fairly non-invasive it's an

ultrasound or a blood draw or amh or

both is there any reason why a woman

would not want to get her follicle

number assessed or her amh levels

assessed is there any reason

why because I was shocked to learn that

most women don't do this until they're

hitting their late 30s or early 40s and

they haven't conceived or they suddenly

decide that they want to conceive and I

thought why doesn't every doctor insist

that their female patients get have

their amh

level addressed so that if they need to

freeze

eggs it's cost yeah so I think if you've

got the disposible income to do it go

for it it's not included in a standard

blood panel no wow the only way women in

my practice who've had amhs done and

have looked at their follicle count are

women who want to freeze their eggs or

and that requires disposable income or

they um are having trouble getting

pregnant so they are in the reproductive

Endocrinology system and they're getting

an evaluation and then they're

also um the women who have symptoms of

early menopause so premature ovarian

insufficiency which is before age

40 uh those are the women that I see

getting attested and I think you're

right that it should be offered more

broadly it speaks to the democratization

of data again and I think most women

don't know that so you're doing a huge

service I think to be speaking into

this one other point related to that is

that what I see in conventional medicine

is that when a woman asks for a hormone

panel and she's not trying to get

pregnant she usually gets told that

hormones vary too much it's a waste of

money you don't need

it or if you're feeling hormonal why

don't you go on a birth control

Bill unless she's trying to get pregnant

if she's trying to get pregnant suddenly

those same tests are very reliable and

they get you know their their

testosterone their free testosterone

their thyroid pain they get their

estrogen and progesterone maybe they get

their cortisol they get their amh so

there's a double standard between those

who want to get pregnant and those who

don't and that needs to end yeah I

totally agree as I've learned more about

um ovulatory cycle and amh and and the

anal population of follicles all it's

fascinating it just seems to me wow a

relatively straightforward test one

definitely invasive ultrasound but I

don't consider that yeah

not terribly invasive but invasive uh at

least but the other one just pure blood

test just seems like why wouldn't why

wouldn't this be offered a covered by

insurance or or you know that anyone

that wanted it but now now I understand

why you mentioned

menopause huge topic enormous topic uh

we had a guest on the podcast who's not

a clinician who said something in

passing so I wanted I likely to get this

wrong um but what they said was that the

results of the large scale trials on

hormone replacement therapy for women

for menopause said something to the

effect of if the hormone therapy was

started early enough it was very

beneficial for yes vitality and health

outcomes whereas if women went through

menopause and then initiated the hormone

therapy hormone replacement therapy that

it could be detrimental to their health

so first of all uh do I recall that

statement correctly and then second of

all what sorts of hormones are being

replaced is it just estrogen and how is

that done is it done through birth

control so oral contraceptives nver

Rings what are your thoughts on

menopause when should people start

thinking about it and what is the pallet

of things available so that we can do an

entire episode with you on on this topic

in the future but just to I you know I

get a lot of questions about this and

and I'm guessing based on everything

you've told me today that there are

women in their 30s that while they may

be 20 years out from menopause probably

should be doing things now in

anticipation of that yes so we haven't

talked about the 30-some but I totally

agree with you the more you know about

your phenotype your hormonal phenotype

when you're in your 30s you're set up in

terms of what to do in the future

especially things like your thyroid your

estrogen and progesterone levels because

you can

replace to a state of you thyroid

whatever that is for you you can replace

I don't usually go exactly back to where

the estrogen and progesterone levels

were were but we can get pretty close so

in your 30s having a base case I think

is really essential so you spoke to the

Women's Health Initiative which was

published in 2002 and we went from a

huge number of women taking hormone

therapy to a very small percentage like

in the range of 5% and that means we've

got millions millions of women who are

suffering needlessly with things like

insomnia difficult with their mood

difficulty with sex drive um feeling

like they are closing the store in terms

of sex because they're not on hormone

therapy I would agree with the statement

that you made that hormone therapy

particular forms that are similar to

what your body always made when it's

given judiciously at the right time

typically within 5 to 10 years of

menopause which is 51 to 52 that it is

incredibly safe so

it's a complicated study the women's

health initiative but it was the the

wrong study in the wrong

patients with the wrong

medications and um with some of the

wrong outcomes so it was powered to look

at cardiovascular outcomes it was not

powered to look at breast cancer it was

stopped because of breast cancer risk

but what happened in the control arm of

the study was that they had an

incredibly low rate of breast cancer and

so as a result they ended up

having this increased risk of breast

cancer at 5 years and they stopped the

study now the study was done with

synthetics it was done with conjugated

equin estrogen known as Premarin and

mroy progesterone acetate those were the

so-called estrogen and progesterone

those are uh synthetic hormones we think

especially the progest is associated

with the greater risk of breast cancer

although the the subsequent

re-evaluations of the data now 18 years

out have shown that um this problem with

the control group and no increased risk

of breast cancer um and for the women

who got estrogen only those who had a

hysterectomy the Premarin they actually

had a decreased breast cancer risk and

decreased breast cancer

mortality so there's a lot to be said

about this I'm trying to keep it really

brief brief but if you look at the women

50 to 60 So within 10 years of menopause

they're the ones who seem to have the

greatest benefit so they had a decreased

subclinical atherosclerosis so less

cardiovascular disease they had an

improvement in terms of um bone

health um less progression to diabetes

and then over the age of 60 they started

to have greater risk of certain outcomes

such as cardiovascular disease

myocardial infection and so

on you asked about

um what do I do

and to me this problem is not just

menopause what's more interesting is to

talk about per menopause so per

menopause is the the period of time

before your final menstrual cycle and

for most women depending on how attuned

you are of the symptoms it can last for

10 years so I'm still in Period

menopause it's been like 20 years

because I've been tracking it so

carefully it usually gets kicked off by

having your cycle get closer together so

that can happen in your 30s or your 40s

you go from 28 days to 25 days that sort

of thing you may notice that you start

sleeping more poorly because

progesterone is so important you talked

about that with Kyle you may notice it

as more anxiety difficulty sleeping and

that probably is related to the estrogen

receptor so e Alpha is estrogen receptor

Alpha is

enio um it increases anxiety ER beta is

associated with an angiolytic activity

and then there's a total of about six

estrogen receptors now there's the the G

protein coupled estrogen receptors and

those are mixed angiolytic

angiogenic so um there's this whole

period of paropa and what's Most

Fascinating to me and we've got to talk

about this either today or another time

is that there is this massive massive

change that happens in the female

brain that people are not talking about

enough and so looking at the work of

Lisa mascone at

Cornell from uh starting around age 40

there is this massive change in cerebral

metabolism so you can do fdg pet scans

you can look at glucose uptake and

there's about on average a 20% decline

from Prem

menopause you know up to like age

35 to per menopause to

postmenopause the women who are having

the most symptoms in per menopause

menopause The Hot Flashes the night

sweats the difficulties sleeping those

are the ones who have the most

significant cerebral hypo

metabolism so it's almost like a um I

don't I don't want to scare people with

this language but it's it's a lowlevel

or let's call it pseudo dementia of

sorts yes it it it seems to be a

phenotype that you can then map to

Alzheimer's disease because that's Lisa

musc's work she's looking at okay

Alzheimer's disease is not a disease of

old age it is disease of middle age what

are some of the biomarkers that we can

Define that can tell you what your risk

is I've got a mother and a grandmother

with Alzheimer's disease you can believe

I am all over this data and insulin

resistance ins sensitivity as we talked

about it before um seems to be somewhere

in there which I think when that first

when that idea first surfaced a few

people are like really but then of

course right I mean the brain is this

incredibly metabolically demanding organ

you deprive neurons of fuel sources they

or you make them less sensitive to fuel

sources they start dying they they

certainly start firing less it makes

perfect sense and I think now it's

thanks to Lisa's work work that you've

you've done in a talked about quite a

lot is um in your books and elsewhere I

think has really you know highlighted

for people that metabolism and

metabolomics is going to be as important

as genes and genomics when it comes to

right dementia perhaps especially in

women is it safe to say that I think I

think so

because we believe that the system is

regulated by

estrogen so the decline in estrogen

starting around age 40 43 is kind of the

average seems to be the driver behind

cerebral hypom metabolism the way I

describe it to my patients is it's like

slow brain energy so you walk into a

room you can't remember why like you

just notice that you can't manage all

the tasks the way that you once could

like things are just a little slower and

I say that to women they're like I have

that like help me so this is then

circling back to Whi where women are

scared to death of taking hormone

therapy and we've got all of these women

that are Marching toward potentially a

greater risk of Alzheimer's disease and

they have this opportunity in their 40s

and their 50s to take hormone therapy

and they may not be offered it because

the typical conventional approach based

on Whi is to say unless you're having

hot flashes and night sweats that are

severe I'm not going to give you hormone

therapy and I I just want to call that

out I would say no that is not the way

to approach

it

further the concept right now in

conventional medicine is that hot

flashes and night sweats are these

nuisance symptoms that we will take care

of temporarily maybe with a little bit

of estrogen progesterone or birth

control pill because it's given a lot or

that they pass this idea you know suck

it up suck it up doesn't matter that

you're not sleeping anymore you know

turn down the temperature in your room

and that's not right because hot fleshes

and night sweats are a

biomarker of cardiometabolic disease

they are a biomarker of increased bone

loss they are a biomarker of changes in

the

brain so many of these symptoms that

occur in perimenopause are not driven by

the ovaries they are driven by the brain

yeah it's the the bidirectional cross

talk between the body and the brain

keeps you know I think is this

resounding theme uh we had Chris Palmer

on here a psychiat who's talking about

ketogenic diet for treat mental health I

know you we could have a whole other

discussion and we will I hope if you'll

agree to it about nutrition and as it

relates to hormones um specific diets

and so forth but the and that's a

question too whether this problem of

cerebral

hypometabolism could we solve it with

estrogen Andor increase metabolic

flexibility so I just wanted to footnote

that sorry to interrupt you no please uh

please interrupt um uh I I know you're

as long as we're there I know you are a

fan in some instances of intermittent

fasting time restricted feeding Andor

ketogenic diet yes um to get cells

sensitive to insulin which is not to say

if I understand correctly which is not

to say that women need to stay on the

ketogenic diet for long periods of time

or intermittent fast by only time

restricted feeding for 8 hours or 6

hours a day but that by increasing you

said met abolic

flexibility excuse me but by increasing

cells sensitivity to insulin and then

maybe returning to a more typical eating

pattern and periodically switching back

and forth that might actually benefic be

beneficial do I have that right yeah I

love the pulse so I feel like it's much

more physiologic than say going on a

ketogenic diet and staying there for

years all of the data that we have on

the ketogenic diet it's pretty Limited

in terms of duration you know the the

longest players that we have in terms of

the data are the folks with epilepsy and

that's just a different phenotype so I

think in terms of microbiome effects

diversity disbiosis some of those issues

we really don't know in terms of

long-term effects so I prefer with a

ketogenic diet that it's used as an nof

one experiment and that you do it for

four weeks maybe you measure biom

merkers before and afterwards maybe look

at your stool before and afterwards and

we still haven't talked about stool

tests yet but you could measure you're

fasting insulin and your glucose you

could just start there do four weeks of

Keto clean keto including vegetables

doesn't have to be 57 a day and then

measure it again

afterwards since you measure mentioned

stool testing yes um what what is your

recommendation about stool

testing so my recommendation this is

again in the the field of if you have

the disposable income so I usually start

with goova because they've got a good

co-pay system with insurance that's what

I typically use so I usually do their

one day stool test where you have to go

digging through your stool and send it

off to this lab that's in North Carolina

I usually do the one day unless I'm

concerned about parasites in that case I

tend to do three days I do that for

people who travel a fair amount and go

to places where there's greater risk or

they just have gut

symptoms another test that I do a lot is

um cuz I was like to mention two Labs is

a test by

longevity and this is much more of a

data

wonk uh type of test because it's

powered by AI it was designed by um a

guy who's got inflammatory bowel disease

and he is

a um he's a

PhD deep phenotyping bioinformatics guy

who wanted to make this really easy so

the test is is under the umbrella of

thorn and um they used call it gut bio

they might have another name for it and

they just improved it so that it's a a

wipe instead of digging through your

stool and so my athletes will do it now

they were not so into digging through

their stool before is anybody really no

one is I don't want the

answer I know the answer I prefer to

that question but that's a super

interesting test because it's you get

much more dense data the issue is um um

with apologies to my friends at Thorne

the issue is that their recommendations

end up being Thorn supplements so that

can be very easy for people who want to

you know connect the

dots that's not always the way that I

like to do it uh first of all three

things um you've shared with us an

immense amount of knowledge uh and in

that first statement I also want to

apologize because I threw you the entire

lifespan of uh female lifespan

reproductive Health contraception diet

uh microbiome so many things but um I

first I just want to say you've taught

me a tremendous amount um including I

think something that most people

including myself have not thought about

enough which is the psychosocial impact

on things that we're all familiar with

constipation bowel movements what we eat

what we avoid I have to say really a

huge thank you for that because it's not

something that's been discussed on this

podcast before sort of know that brain

communicates with body psychology and

biology are linked but I think this is

the first time that anyone's ever

directly

linked circumstances and biology and

psychology in such a concrete way so

that's the that's the first thing and I

I speak for many people on that second

of all we barely scratch the surface of

your know knowledge and um which is both

uh frustrating for me because uh it I

always want to learn more and I know

many other people do as well but also

very very exciting because uh with uh

hopefully without much persuasion we can

have you back on to talk about pers at

all like men uh I know you're working

with men now Men's Health um some

particulars around per I think there's

more for us to explore in terms of PCS

menopause contraception and all of the

above but then something that you and I

were talking about off camera um before

started which I think is a really

important factor that ties back to this

issue of of trauma and stress and the

bidirectional relationship between

biology and psychology hopefully someday

we won't even separate those two um

which is the use of specific medicines

including plant medicines yes and how

that can influence overall health which

no doubt will include Hormone Health so

I say all of that for two reasons first

of all to queue up the we won't even

call it a part two but a equal to to

this which um I'm gratified to hear that

you you'll join us for that and then

also to just really extend a huge thank

you the amount of knowledge that you

shared is is immense and uh is going to

be very very useful and actionable for

for men in terms of their thinking and

their actions and for women in

particular today's discussion in

particular for women in terms of how to

think about their health and biology how

to think about their psychology and the

environment that all of that embedded in

so I just want to say an enormous thank

you thank you Andrew I so appreciate

that and I so appreciate what you offer

to the world in terms of a way in a way

to understand physiology and how to

craft a architect a better

life um can I just add one last thing

because I didn't talk about it since we

didn't get to the 40s and the 50s in

this list of biomarkers to so I feel

like if people if women went away with

one thing today

it would be to do a coronary artery

calcium score by age 45 and sooner if

you've got premature heart disease how

is that taken so it's a CT scan of the

chest you can self-order it like I think

at Stanford Hospital you can self-order

it last time a patient checked it was

$250 so again disposable income but it

it tells you it it almost gives you this

fork in the road in terms of how much

you need to pay attention to

cardiometabolic health as a woman and

it's 45 for men too so if you haven't

had one have you had one no you need one

insulin cortisol CAC great so I'll run

all that by you it's really essential

and it's

um yeah it's it's so fascinating because

you know there's some women who have a

zero so my score is zero and that's

great so often you can just keep doing

what you're doing but if you're 45 and

you're starting to be elevated or you've

got you know maybe you've got PCOS or

you've got some other biomarkers tending

you in this direction toward the number

one killer really eight to nine out of

the top 10 killers in the

US that allows you to really start to

make changes and I I think it's

essential to know that data it's not

it's probably not going to be offered by

your doctor certainly Peter AA is going

to offer it but most conventional

doctors are not going to do it and then

the last thing I want to say before you

mention so if I were to go to my doctor

and I just say I want a a cardiac

calcium score that's what people

coronary artery calcium score CAC okay

so everyone hear that and know that if

you're 40 or older and maybe if you're

45 or older get get it so the last thing

is and this for men and women is your a

score so adverse childhood

experiences knowing your a score is so

essential in terms of a baseline for how

much trauma your system your Pine system

endured when you were a kid and we know

that childhood trauma whether it's abuse

or neglect or you know having an

alcoholic parent that maps to disease in

middle age and it can give you so much

Insight I'll give you an example I've

got a patient who had an elevated

coronary artery calcium score who does

everything right with her food I think

it was her trauma that elevated her C

when she was 45 so I think an a score

knowing your a score

starting as a teenager like knowing it

and knowing how to work with that is

really essential there are certain

people they are exceedingly rare but you

are one such person that when they speak

knowledge just comes from comes out of

them and it's incredibly useful and

helpful knowledge so thank you I'm going

to get both of those things good um and

I highly recommend everyone else pursue

ways that they can get those or if they

can't get them that they you know

earmark those as things to get at the

point where they they can obtain

sufficient uh disposable income sounds

like that the health uh the detriments

to health that those can offset would be

well worth the cost

totally thank you thank you for joining

me for today's discussion all about

female hormone Health vitality and

Longevity with Dr Sarah gotfried if

you'd like to learn more about Dr gotf

Freed's work please check out her social

media channels we've provided links to

those in the show note captions in

addition please check out one or all of

Dr G reads excellent books that she's

written about nutrition supplementation

and various treatments for Hormone

Health longevity and vitality we've

linked a two of those notably women food

and hormones and her book the hormone

cure in our show note captions if you're

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