Beyond HRT: Hormone Vitality & Longevity with Dr. Sara Gottfried

# tactiq.io free youtube transcript
# Dr. Sara Gottfried: How to Optimize Female Hormone Health for Vitality & Longevity | Huberman Lab
# https://www.youtube.com/watch/GVRDGQhoEYQ

00:00:00.179 welcome to the huberman Lab podcast
00:00:01.920 where we discuss science and
00:00:03.959 science-based tools for everyday life
00:00:08.880 I’m Andrew huberman and I’m a professor
00:00:10.920 of neurobiology and Ophthalmology at
00:00:13.259 Stanford school of medicine today my
00:00:15.299 guest is Dr Sarah Gottfried Dr Sarah
00:00:17.580 Gottfried is an obstetrician
00:00:19.199 gynecologist who did her undergraduate
00:00:21.359 training in bioengineering at the
00:00:23.340 University of Washington in Seattle she
00:00:25.619 then completed her medical training at
00:00:27.300 Harvard Medical School and she currently
00:00:29.279 is a clinical professor of Integrative
00:00:30.960 Medicine and nutritional Sciences at
00:00:32.940 Thomas Jefferson University she has also
00:00:35.520 been a clinician treating men and women
00:00:38.040 in various aspects of Hormone Health and
00:00:40.559 Longevity for more than 20 years
00:00:43.140 she is an expert in not just traditional
00:00:45.480 medicine as it relates to hormones and
00:00:47.160 fertility but also nutritional practices
00:00:49.860 supplementation and behavioral practices
00:00:51.960 and combining all of that expertise in
00:00:54.719 order to help women navigate every
00:00:56.399 aspect and dimension of their hormones
00:00:58.379 longevity and vitality ranging from
00:01:00.780 puberty to Young adulthood adulthood
00:01:04.040 perimenopause and menopause and nowadays
00:01:06.720 she’s also treating men across the
00:01:08.939 lifespan in terms of longevity vitality
00:01:10.979 and Hormone Health during today’s
00:01:12.659 discussion Dr Gottfried shares an
00:01:14.400 enormous amount of information and tools
00:01:16.799 that women can apply toward their
00:01:18.600 Hormone Health fertility vitality and
00:01:21.060 longevity we discussed the gut
00:01:23.220 microbiome which many people have heard
00:01:24.780 about but Dr Godfrey points out the
00:01:27.000 specific needs that women have in terms
00:01:28.619 of managing their gut microbiome and the
00:01:30.720 ways that that influences things like
00:01:32.340 estrogen levels and Metabolism
00:01:33.840 testosterone thyroid and growth hormone
00:01:36.060 and much more we also discussed
00:01:38.280 nutrition and exercise we touch on how
00:01:40.979 the omega-3 fatty acids play a
00:01:42.900 particularly important role in managing
00:01:44.820 female hormone Health Dr Gottfried
00:01:46.740 points out why women have particular
00:01:48.479 needs when it comes to essential fatty
00:01:50.460 acids and how best to obtain those
00:01:52.380 essential fatty acids for Hormone Health
00:01:54.360 we also discuss exercise and she offers
00:01:57.899 some surprising information about the
00:01:59.759 types and ratios of resistance training
00:02:02.100 to cardiovascular training that women
00:02:04.200 ought to use in order to maximize their
00:02:05.939 Hormone Health
00:02:07.020 we also talk a lot about the digestive
00:02:09.060 system this was a surprising aspect of
00:02:10.860 the conversation I did not anticipate Dr
00:02:12.780 Gottfried shared with us for instance
00:02:14.280 that women suffer from digestive issues
00:02:16.440 at more than 10 times the frequency that
00:02:18.360 do men and fortunately that there are
00:02:20.400 tools specific to women that they can
00:02:22.319 use in order to overcome those digestive
00:02:24.420 issues and that in overcoming those
00:02:26.760 digestive issues they can overcome many
00:02:28.739 of the related hormone issues that so
00:02:30.780 many women face Dr Gottfried also shares
00:02:33.120 with you tremendous knowledge about the
00:02:35.220 specific types of tests not just blood
00:02:36.959 tests but also urine and microbiome
00:02:38.760 tests that women can use in order to
00:02:41.459 really get a clear understanding of
00:02:43.440 their hormone status not just of present
00:02:46.319 but also where the trajectory of their
00:02:48.780 hormones is taking them so we have an
00:02:50.819 avid discussion about puberty about
00:02:53.220 young adulthood adulthood perimenopause
00:02:55.920 and how best to manage and navigate
00:02:57.780 perimenopause and menopause including a
00:03:01.019 discussion about hormone replacement
00:03:02.220 therapy in addition to her academic and
00:03:04.560 clinical expertise Dr Gottfried has
00:03:06.360 authored many import important books on
00:03:07.980 nutrition hormones and supplementation
00:03:10.019 as it relates to women and to people
00:03:12.180 generally the two books that I’d like to
00:03:14.340 highlight and that we’ve provided links
00:03:15.780 to in the show note captions are women
00:03:17.819 food and hormones and the hormone cure I
00:03:20.760 read the hormone cure and found it to be
00:03:22.500 tremendously interesting and informative
00:03:24.180 not just in terms of teaching me about
00:03:25.920 female hormone health and various
00:03:27.300 treatments for female hormone Health but
00:03:29.400 also as a man trying to understand how
00:03:31.860 the endocrine system interacts with
00:03:33.599 mindset nutrition and supplementation
00:03:35.700 more generally so I highly recommend the
00:03:37.800 hormone cure for anybody interested in
00:03:39.659 hormones and Hormone Health and women
00:03:41.400 food and hormones in particular for
00:03:43.140 women although again both books are
00:03:45.360 going to be strongly informative for
00:03:46.860 women wishing to optimize their Hormone
00:03:48.780 Health vitality and Longevity before we
00:03:51.420 begin I’d like to emphasize that this
00:03:53.040 podcast is separate from my teaching and
00:03:54.720 research roles at Stanford it is however
00:03:56.879 part of my desire and effort to bring
00:03:58.799 zero cost to Consumer information about
00:04:00.659 science and science related tools to the
00:04:02.819 general public in keeping with that
00:04:04.620 theme I’d like to thank the sponsors of
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00:07:46.080 huberman and now for my discussion with
00:07:48.599 Dr Sarah Gottfried Dr Gottfried Sarah
00:07:51.180 welcome thank you so happy to be here
00:07:53.580 yeah I’m delighted and very excited to
00:07:55.680 ask you about an enormous number of
00:07:57.479 topics here we are expert in so so many
00:07:59.940 things so uh the challenge for me is
00:08:02.280 going to be to constrain this walk as it
00:08:05.400 were but I’m hoping that we can touch on
00:08:07.680 a great number of things today the first
00:08:10.020 of which
00:08:11.120 is really about
00:08:13.500 hormones and female hormones in
00:08:16.020 particular and I have a question which
00:08:18.360 is
00:08:19.919 is it ever informative for a woman
00:08:22.379 regardless of age to know something
00:08:24.419 about
00:08:25.319 her mother’s perhaps even her
00:08:27.479 grandmother’s experience vis-a-vis
00:08:29.819 hormones not just pregnancy
00:08:32.760 challenges with or
00:08:35.039 um ease with pregnancy and child rearing
00:08:38.219 childbirth this sort of thing but you
00:08:40.380 know what sorts of conversations should
00:08:42.240 women be having with themselves and with
00:08:44.820 family members to get a window into what
00:08:47.580 their specific needs might be love this
00:08:50.519 question
00:08:51.540 so my work is really at the interface
00:08:54.240 between genetics and environment so your
00:08:57.240 question gets to
00:08:58.800 both
00:09:00.120 and I think it’s essential that you
00:09:02.519 understand
00:09:03.500 what your
00:09:05.279 grandmother went through I’d even say
00:09:07.440 your great grandmother depending on
00:09:08.640 longevity in your family so I grew up
00:09:10.560 with my great-grandmother I get that
00:09:12.779 and especially your mother
00:09:14.940 so
00:09:16.140 I would probably start first with trauma
00:09:19.380 an intergenerational trauma because I
00:09:21.839 think that affects the endocrine system
00:09:24.060 so hugely especially cortisol signaling
00:09:26.880 but
00:09:28.440 the broader Pine system
00:09:31.820 psychoimmunuroendocrine system
00:09:34.080 and then there’s you know if I think
00:09:35.820 about
00:09:37.320 the stages the life cycle that a woman
00:09:39.660 goes through
00:09:41.339 if you think about puberty I think I
00:09:44.700 don’t know how
00:09:46.260 genetically determine the age of puberty
00:09:48.480 is certainly there’s a lot of
00:09:49.800 environmental influences like toxins can
00:09:52.740 affect it
00:09:54.060 but
00:09:55.440 um pregnancy
00:09:58.019 the age at which you start to go through
00:10:00.120 perimenopause menopause many of those
00:10:02.880 have a genetic component
00:10:05.880 so with pregnancy I mean you can
00:10:07.380 certainly think
00:10:08.940 the shape of the pelvis your ability to
00:10:11.700 have a vaginal birth
00:10:13.620 some of that is genetically determined I
00:10:15.420 mean you do have you know the the sperm
00:10:18.000 donor affecting some of that but you
00:10:21.240 know in my family for instance we have
00:10:22.740 no cesarean sections so everyone goes
00:10:26.100 through this process of a relatively
00:10:28.920 easy vaginal birth I was a forceps baby
00:10:31.800 but you know for the most part
00:10:34.860 um you can find out about that and then
00:10:36.300 there’s certain female conditions that
00:10:39.600 have a very strong component genetically
00:10:42.779 most of which run in my family so that
00:10:45.720 includes endometriosis
00:10:48.019 fibroids I just had a hysterectomy I
00:10:51.420 added 50 plus fibroids
00:10:53.700 and polycystic ovarian syndrome
00:10:57.120 and of those three uh how frequent are
00:10:59.760 those and maybe I can constrain the
00:11:02.100 question a little bit by saying
00:11:03.779 um today’s discussion I imagine is going
00:11:05.579 to be heard by men and women of all
00:11:07.200 sorts of Ages so I uh maybe I’ll direct
00:11:09.360 the question a little bit toward you
00:11:11.519 know at what age should these
00:11:12.779 discussions start
00:11:15.180 um you know we always imagine that women
00:11:18.180 in their 30s and 40s and 50s and onward
00:11:21.300 should be getting certain tests and
00:11:23.220 addressing things like uh ovarian
00:11:25.680 reserve and and other sorts of things
00:11:27.839 but you know maybe we could March
00:11:30.180 through and just say for a woman in her
00:11:33.000 teens who’s already hit puberty what
00:11:35.700 sorts of biomarkers whether or not
00:11:37.620 they’re blood-based or per or
00:11:39.839 um phenotyping you know the outward
00:11:42.000 appearance of uh
00:11:43.860 should those young women be paying
00:11:46.019 attention to likewise for women in their
00:11:47.940 20s 30s maybe we could take it more or
00:11:49.980 less by by decade at starting at puberty
00:11:52.560 assuming that woman hits puberty
00:11:54.360 sometime what between what is it now the
00:11:56.459 average in the U.S is somewhere between
00:11:57.839 12 and 16 years old do I have that right
00:12:00.240 no you do not oh great so that’s to be
00:12:02.640 wrong so so it used to be 12 to 16. I
00:12:07.140 would say 50 years ago
00:12:09.480 it’s been moving younger and we think
00:12:13.560 some of that is related to toxin
00:12:15.360 exposure as I mentioned but I was 10
00:12:17.880 when I went through puberty so uh well I
00:12:21.480 should say menarchy and I started
00:12:24.120 growing breasts much before that so
00:12:27.480 I think
00:12:29.579 now I’m going to step away from the
00:12:30.899 science for a moment I’m going to do
00:12:32.160 that pretty fluidly and I’ll try to call
00:12:33.779 it out
00:12:34.980 I think there’s also a huge influence
00:12:37.260 from stress
00:12:39.060 and like the development of the adrenal
00:12:41.160 glands
00:12:42.360 so going back to the science
00:12:46.019 the issue in teenage years is that the
00:12:50.760 hypothalamic pituitary adrenal axis
00:12:54.600 and I like to think of it broader so
00:12:58.019 stay with me hypothalamic pituitary
00:13:00.240 adrenal gonadol a recent women testes
00:13:04.019 men
00:13:04.860 thyroid
00:13:06.360 gut axis
00:13:08.100 so that to me is the control system so
00:13:10.620 I’m kind of
00:13:12.000 expressing my bioengineering side here
00:13:14.220 well I think it’s great to include the
00:13:15.660 other organs and tissue systems of the
00:13:17.459 body because as we both know that the
00:13:19.980 narrow definition of just hypothalamic
00:13:21.959 pituitary adrenal it can’t be just that
00:13:24.600 right no it can’t no yeah it doesn’t
00:13:27.480 tell the whole story
00:13:28.980 so if you look at
00:13:31.079 the
00:13:32.279 the main sex hormones
00:13:34.620 in a a young woman who’s in her teenage
00:13:37.260 years the hypothalamic pituitary adrenal
00:13:40.260 gonadal part of that is not fully mature
00:13:43.980 so they’re more likely to skip periods
00:13:45.959 especially under stress they have a lot
00:13:49.200 of influences it really doesn’t get well
00:13:51.000 established until you’re done with
00:13:52.980 adolescence and I’m told that
00:13:54.959 adolescence now is still like age 25 to
00:13:57.300 26. I heard that and I was like I’ve got
00:14:00.240 two daughters and I was like that’s a
00:14:02.339 really long time and not just a
00:14:04.380 psychologically defined or bio
00:14:06.800 psychosocial mostly psychologically
00:14:09.480 defined I heard that from a psychologist
00:14:13.260 so
00:14:15.300 biomarkers you asked about in your
00:14:17.760 teenage years what I think is really
00:14:19.440 interesting is to look at cortisol
00:14:22.440 to look at the dance between estrogen
00:14:25.260 and progesterone in those years is less
00:14:27.839 helpful because I think there’s a lot of
00:14:30.120 variability due to the immaturity of the
00:14:32.160 system if you’ve got someone who’s got
00:14:34.320 really regular periods it’s probably
00:14:36.360 better to do some benchmarking at that
00:14:38.339 age but generally I find that
00:14:40.019 benchmarking
00:14:41.579 is best performed in your 20s or 30s are
00:14:44.760 periods not that regular in terms of
00:14:46.740 duration of the menstrual cycle when the
00:14:50.579 menstrual cycle first sets in
00:14:52.620 it depends so I was like clockwork every
00:14:55.980 28 days until I had my hysterectomy in
00:14:58.860 August
00:15:00.120 same thing with my daughters I’ve got
00:15:02.160 two daughters one’s 17 the other is 23.
00:15:06.420 for a lot of women they’re not regular
00:15:09.120 and then there’s the whole piece of oral
00:15:12.060 contraceptives and other forms of
00:15:13.800 contraception where you have no idea
00:15:16.019 what the normal cycle is and I hope
00:15:18.420 we’ll have some time to talk a little
00:15:20.100 bit about oral contraceptives because I
00:15:22.019 think it is
00:15:23.279 this is now opinion again and not
00:15:25.440 science I think it is the number one
00:15:27.600 endocrinopathy
00:15:29.579 that is iatrogenic for women uh we will
00:15:33.360 definitely talk about it I get a lot of
00:15:34.860 questions about oral contraceptives
00:15:36.779 um in the social media space and also
00:15:40.139 questions about iuds quite a lot totally
00:15:43.620 in particular copper iuds
00:15:45.560 non-non-hormonal IUD so we will
00:15:47.579 definitely touch on that I’m an IUD
00:15:49.560 Crusader so I just want to you know give
00:15:52.139 you that warning you’re you’re a fan do
00:15:54.120 I have that right or you’re anti I am a
00:15:56.100 huge fan which iuds in particular so I
00:15:59.639 like copper because it’s non-hormonal
00:16:03.420 it’s as effective as getting your tubes
00:16:05.880 dyed who would have thought right I mean
00:16:07.740 it’s that toxic to the sperm Mobility is
00:16:09.720 that how it works that’s my
00:16:11.399 understanding of it is that that it that
00:16:12.899 it basically it’s like a
00:16:15.139 more or less an electric fence to the
00:16:17.519 the sperm cap and just that’s it
00:16:19.199 electric fence is a bit of a harsh
00:16:21.779 analogy but I’ll work with that
00:16:24.120 but it’s
00:16:26.699 it’s for 10 years so that you really
00:16:28.680 have
00:16:29.940 complete autonomy and sovereignty over
00:16:32.699 your sexual life
00:16:34.380 that’s profound and to not get all those
00:16:37.019 Downstream risks they’re associated with
00:16:38.880 a birth control pill the other thing
00:16:40.259 that’s important to know about it I know
00:16:41.639 this is a sidebar
00:16:43.500 women who use the copper IUD
00:16:46.560 have the highest satisfaction rate of
00:16:49.560 anyone on contraceptives the highest
00:16:53.040 satisfaction rate and yet it is the
00:16:56.820 least used of all forms of contraception
00:16:59.519 now my favorite is vasectomy
00:17:02.639 but short of vasectomy I think the IED
00:17:05.579 is a really great choice there are some
00:17:07.199 risks associated with it I’m not saying
00:17:08.640 it’s risk-free but I love IUD and I love
00:17:12.419 it for younger women too because it used
00:17:14.640 to be that when I went through my
00:17:16.260 training which was 30 years ago we were
00:17:19.619 told you know don’t put it in someone
00:17:21.179 who hasn’t had a baby
00:17:23.040 and that is patriarchal messaging
00:17:25.799 but getting back to your original
00:17:26.880 question which is about biomarkers per
00:17:29.400 decade
00:17:31.799 in your 20s
00:17:33.900 that’s when you want to do some base
00:17:36.000 casing with estrogen progesterone and
00:17:38.760 testosterone
00:17:40.080 so I think it’s really helpful to know
00:17:42.120 about this this Tango you’re from
00:17:45.120 Argentina or your father I have
00:17:46.919 Argentine lineage yes my grandparents
00:17:49.320 did Tango into their late 80s I I am I’m
00:17:53.700 in my late 40s and I I still haven’t
00:17:55.559 started so I suppose there’s time it
00:17:57.600 might be time for you to okay and it
00:18:00.900 might be a factor in their longevity did
00:18:03.539 they have good health span and my
00:18:06.179 grandfather Smoked Cigarettes daily
00:18:08.299 remained mentally sharp until he died in
00:18:10.620 his late 90s but um almost burned down
00:18:13.140 their apartment several times falling
00:18:14.400 asleep with a cigarette in his mouth so
00:18:15.780 I don’t recommend anyone Smoke by the
00:18:17.580 way uh but it was uh coffee mate uh red
00:18:20.460 meat and cigarettes and they lived into
00:18:21.840 their 90s so that side of my family has
00:18:24.120 the genetic Advantage the other side
00:18:26.340 less so
00:18:27.539 um but in any event uh Tango
00:18:30.240 um is a 2023 goal it has been every year
00:18:33.900 um the uh I’m gonna hold you accountable
00:18:36.960 today okay we’ll do and there no there
00:18:38.760 will be no YouTube video of me do at
00:18:41.520 least not initially Tim Ferriss actually
00:18:43.500 a phenomenal podcaster as we know is uh
00:18:45.900 he’s a badass he’s a badass Tango Tango
00:18:48.660 dancer I know this through various
00:18:50.220 sources yes yeah I’ve seen yeah so this
00:18:53.280 Tango between us and progesterone is
00:18:55.200 incredibly important you want to have
00:18:57.360 the right lead do you want to have the
00:18:59.160 right follow between the two hormones
00:19:01.740 again I’m stepping away from my science
00:19:03.480 hat but what happens a lot of the time
00:19:06.720 is that estrogen dominates in that Tango
00:19:09.900 and when that happens it sets you up for
00:19:13.140 greater risk of fibroids endometriosis
00:19:16.460 breast pain
00:19:19.080 probably in association with the
00:19:22.500 microbiome and the estrobolume can you
00:19:25.559 familiarize me with the estrobloom yeah
00:19:27.419 I’m delighted to know that I don’t
00:19:29.580 recognize the term yeah so the
00:19:31.799 estrobolume is the set of microbes
00:19:35.220 in and their DNA their DNA mostly
00:19:38.460 in the gut microbiome that set of
00:19:41.460 microbes in their DNA so it’s in the
00:19:44.940 if you look at the totality
00:19:47.640 the subset
00:19:49.260 of particular bacteria modulate estrogen
00:19:53.700 levels
00:19:55.020 so a lot of this work was spearheaded by
00:19:57.120 Martin Glaser
00:19:59.340 and
00:20:00.780 what we know is that there are some
00:20:02.820 women who have an estrobolume that makes
00:20:06.960 them have a greater risk of certain
00:20:09.559 estrogen mediated
00:20:11.880 conditions like breast cancer
00:20:13.640 endometrial cancer
00:20:15.840 and a men prostate cancer
00:20:18.299 so the estrobulum is incredibly
00:20:19.860 important there’s not a lot of attention
00:20:21.840 paid to it but I always think in terms
00:20:25.020 of my patients you know could this be
00:20:27.360 someone who’s got a faulty a strobe and
00:20:30.840 we need to adjust it with you know some
00:20:34.559 of the microbiome
00:20:36.860 modulating
00:20:38.400 uh nutrients nutraceuticals that we have
00:20:40.919 so that they’re less likely to have that
00:20:43.679 that Tango that’s not working with
00:20:45.419 estrogen progesterone so getting back to
00:20:47.640 the biomarkers
00:20:50.760 if if you gave me an unlimited budget
00:20:53.760 which I kind of have with some of my
00:20:56.580 um clients that I work with now
00:20:58.799 what I would want to know is
00:21:01.440 estrogen progesterone testosterone and I
00:21:04.320 want the timing right for that
00:21:06.419 I’d want to know about DHEA and sort of
00:21:08.700 the whole Anderson pathway I’d want to
00:21:11.160 know about the metabolites of estrogen
00:21:12.840 because some of them are protective and
00:21:16.860 very helpful others are a bit like
00:21:20.340 Homer Simpson I mean they’re just like
00:21:22.440 causing all kinds of problems in your
00:21:24.419 body increasing the risk of Quinones
00:21:27.600 like DNA damage and potentially an
00:21:31.740 increased risk of breast cancer although
00:21:33.600 that data I think is mixed
00:21:36.960 I’d also like to know about their stool
00:21:38.940 so I want to know about the microbiome
00:21:41.220 so the best that we have right now is to
00:21:43.140 look uh when we do stool testing I do a
00:21:46.020 lot of stool testing we can look at
00:21:47.940 things like beta glucoronidase
00:21:50.880 are you familiar with BG I’m familiar
00:21:53.340 with it as a term and so for those
00:21:55.200 listening it very often not always when
00:21:57.780 you hear an ace ASE you’re dealing with
00:21:59.460 an enzyme so we can take a stab there
00:22:02.159 and and it sounds like it’s somehow
00:22:04.260 involved in
00:22:05.580 um glucose metabolism of some sort or is
00:22:08.580 it clickeronautation so it’s involved in
00:22:11.640 when you produce estrogen in the body
00:22:14.700 this is like the simplified version but
00:22:16.919 when you produce estrogen you are meant
00:22:20.220 to use it like send it to The receptors
00:22:23.400 where it’s meant to go and then lose it
00:22:25.740 like you don’t want to keep
00:22:27.000 recirculating the estrogen like Bad
00:22:28.860 Karma and that’s what happens with
00:22:31.200 people who have high blade beta
00:22:33.780 gluconidase so it’s this enzyme that’s
00:22:36.299 produced by three bacteria in particular
00:22:38.280 in the gut and I see a lot of men and
00:22:41.100 women who have elevated beta
00:22:43.919 glucuronidase and then they have some
00:22:46.080 estrogen dominance related to that is
00:22:48.299 that the total reason we don’t really
00:22:50.159 know but it’s one of the drivers it’s
00:22:52.380 one of the levers and it can be detected
00:22:54.240 from a microbiome AKA stool sample
00:22:56.820 that’s right and in terms of blood
00:22:59.220 testing or various tests for these other
00:23:01.559 biomarkers getting estrogen testosterone
00:23:04.080 and other ratios I realize there are
00:23:06.480 people have different means financial
00:23:08.460 means but in general people wanting to
00:23:11.580 do a blood test it sounds like they’re
00:23:12.840 going to need to do it what women will
00:23:14.340 need to do it at different stages of
00:23:15.600 their menstrual cycle if they had to
00:23:16.980 pick one
00:23:18.179 you know either in the follicular phase
00:23:21.179 and or in the luteal stage of their
00:23:24.179 ovarian menstrual cycle excuse me
00:23:25.799 ovulatory menstrual cycle
00:23:27.539 when would you suggest they do that if
00:23:29.640 they had to pick one so if you forced me
00:23:32.220 to pick one I would say
00:23:34.320 probably day 21 to 22 for someone in her
00:23:38.700 20s so we’re focused right now in that
00:23:41.280 decade
00:23:42.240 so for most women they’ve got a
00:23:44.039 menstrual cycle Dave that averages out
00:23:46.200 at 28 days so this is about a week
00:23:48.360 before they start their period
00:23:51.360 for women or more irregular it’s harder
00:23:53.580 to do that as women get older and we’ll
00:23:56.159 talk about this in a moment
00:23:57.840 usually the cycle gets a little shorter
00:23:59.940 so as they start to decline in their
00:24:02.700 progesterone production their period
00:24:04.620 gets a little closer together like mine
00:24:06.539 before August was about every 26 days
00:24:09.900 so
00:24:11.880 at that point you want to test sooner
00:24:14.100 like day 1920 and I’m not talking about
00:24:16.919 blood tests so a blood test is the
00:24:18.600 cheapest thing it’s usually what’s
00:24:19.620 covered by insurance but my preference
00:24:22.200 would be to do dried urine
00:24:24.480 I like to use saliva for cortisol I like
00:24:27.480 to use dried urine so that I get
00:24:29.039 metabolomics in addition to the levels
00:24:31.140 of these hormones and if I’m forced to
00:24:33.780 I’ll use blood testing and that’s
00:24:35.640 certainly the gold standard
00:24:37.500 for all of these hormones that we’re
00:24:39.360 talking about
00:24:41.100 but
00:24:42.360 um it’s not as comprehensive and as you
00:24:44.460 know it’s a quick little snapshot while
00:24:46.140 the needle’s in your vein for you know
00:24:48.000 30 seconds yeah the salivary cortisol
00:24:50.640 makes sense to me because my
00:24:51.659 understanding is that you get free
00:24:52.679 cortisol which is the active cortisol
00:24:54.419 you said with urine you’re also getting
00:24:55.860 the metabolites that’s right and then
00:24:58.620 um for blood testing you’re getting it
00:25:00.900 it’s sort of a crude window into the
00:25:02.520 averages ecstatic total level
00:25:06.780 so uh let me go back and say one other
00:25:09.960 thing about biomarkers a big part of the
00:25:12.120 testing that I do in phenotyping my
00:25:14.280 patients I practice Precision medicine
00:25:16.440 so I I like to
00:25:19.400 almost start with nutritional testing
00:25:24.360 I don’t think I’ve ever had a teenager
00:25:26.760 I’ve got some NBA players that are 19 20
00:25:29.340 21 so maybe those count
00:25:31.860 but uh those are men obviously but for
00:25:35.640 nutritional testing
00:25:37.980 that would be a potentially a helpful
00:25:39.840 thing to do in your 20s becomes less
00:25:42.179 important as you get older and you
00:25:43.559 develop more micronutrient deficiencies
00:25:45.539 but micronutrients play a huge role in
00:25:48.960 terms of hormone production magnesium
00:25:51.179 you know the Magnesium is hugely
00:25:53.400 involved in the way that you get rid of
00:25:55.260 estrogen as an example
00:25:57.240 so micronutrient testing what I usually
00:25:59.220 do is a combination of blood and urine
00:26:02.159 and so I’m looking at all of the
00:26:03.960 micronutrients that we can measure that
00:26:06.600 have some clinical scientific basis
00:26:09.900 behind them
00:26:11.760 if I could do that for a teenager I
00:26:14.400 think it might be helpful because
00:26:17.340 I recently gave a lecture on breast
00:26:19.440 cancer risk reduction
00:26:21.659 another quick sidebar
00:26:23.940 and I was sad to find that
00:26:28.919 intake of vegetables polyphenols is such
00:26:32.940 an important predictor a future risk of
00:26:35.460 breast cancer like when you’re a 50 60
00:26:37.380 plus and the most important time is when
00:26:40.620 you’re a teenager
00:26:42.120 now I have one daughter that eats
00:26:43.799 vegetables she loves them and I have
00:26:45.600 another daughter who eats food that’s
00:26:47.159 beige and it’s very hard to get her to
00:26:50.580 eat the volume of vegetables you know
00:26:52.740 five colors a day which is what I do
00:26:55.380 and
00:26:57.419 if you have evidence that you could show
00:27:00.720 a 17 year old that they’ve got
00:27:03.240 micronutrient gaps
00:27:06.960 I think that would be a motivator for
00:27:08.880 them to eat differently at a time when
00:27:11.220 it’s so critical
00:27:13.020 even though it’s you know 25 years in
00:27:15.299 the future that it’s going to
00:27:16.320 potentially change this Arc that they’re
00:27:18.240 on
00:27:19.140 what do you do for a young woman who
00:27:21.720 doesn’t like vegetables is or is not
00:27:24.779 somehow able or willing to to get those
00:27:27.600 five colors a day of vegetable to help
00:27:30.779 support the microbiome
00:27:32.940 you know our supplements a useful tool
00:27:35.880 in that case
00:27:37.080 um what other sorts of tools Behavioral
00:27:38.820 or otherwise are useful such a good
00:27:41.220 question so here I’m going to invoke Rob
00:27:43.140 Knight at UCSD
00:27:45.240 so I think his his uh his gut project
00:27:49.140 has really been helpful in terms of
00:27:51.240 understanding what kind of modulators
00:27:53.159 are going to be important
00:27:55.440 so what I try to get that person to do
00:27:57.659 and I don’t see many teens anymore other
00:27:59.940 than NBA players
00:28:01.740 what I try to get them to do is to have
00:28:03.299 a smoothie
00:28:04.980 very hard to get them to have a smoothie
00:28:06.659 every day but if I could get them to
00:28:08.100 have a smoothie three times a week and
00:28:10.380 to throw some of these vegetables in
00:28:12.000 that makes a huge difference I mean we
00:28:14.340 know that makes a difference in terms of
00:28:15.840 microbiome change she should be blending
00:28:18.179 up broccoli or kale cauliflower so
00:28:20.760 cauliflower is great even they’re
00:28:22.559 putting things into the Smoothie yeah I
00:28:24.600 don’t know if you can get a teenager to
00:28:25.860 do that but they often will use like I
00:28:27.960 have them do steamed broccoli that’s in
00:28:30.000 the freezer because it’s got very little
00:28:31.500 taste
00:28:32.760 so that they could do that in a
00:28:34.679 chocolate smoothie they could add some
00:28:36.299 greens I like greens powders are super
00:28:39.600 convenient so that with you know kind of
00:28:42.480 a taste that they like whether that’s
00:28:44.340 chocolate which is what most my clients
00:28:46.679 want or you know vanilla with berries
00:28:49.559 and that sort of thing so that can go a
00:28:51.539 long way if you don’t like vegetables
00:28:53.340 and short of that I would say some
00:28:55.559 supplements but I would say that’s a
00:28:57.179 distant second to making a smoothie I’ve
00:28:59.640 got one patient that I have to mention
00:29:01.919 because
00:29:03.840 um
00:29:05.340 he took us to the extreme so he is a
00:29:08.880 retired physicist professor at UCSD he
00:29:12.659 found out that his microbiome was a hot
00:29:14.400 mess
00:29:15.240 and developed autoimmune disease and so
00:29:19.380 he became hell-bent like only a
00:29:21.899 physicist could on changing his
00:29:24.179 microbiome and he dramatically shifted
00:29:27.120 it by having a smoothie every day with
00:29:31.380 57 vegetables and fruits in it 57
00:29:35.520 independent 57 independent so
00:29:39.299 I mean this just warms my heart the way
00:29:43.080 that he did this but he would go to the
00:29:45.059 farmer’s market he would just get a
00:29:46.919 bunch of this a bunch of that
00:29:48.779 and he would go home make the smoothie
00:29:51.120 and then stick it in the freezer so he’d
00:29:53.159 have a serving every day and he became a
00:29:56.700 completely different person based on
00:29:59.159 this microbiome change his
00:30:01.919 uh autoimmune disease is in remission
00:30:06.120 he um
00:30:08.039 he dropped a huge amount of weight he
00:30:11.159 went from being you know kind of this
00:30:12.600 phenotype that I know you know well of a
00:30:15.960 professor High performing traveling
00:30:17.640 around the world on so many boards so
00:30:20.220 much Innovation so many great ideas
00:30:21.960 super computer guy to being someone who
00:30:25.380 gets up in the morning gets in his hot
00:30:27.000 tub exercises for like one to two hours
00:30:30.000 a day
00:30:30.899 and then does a little work like he
00:30:33.480 completely shifted the way that he lives
00:30:35.340 and his microbiome shift you know who
00:30:37.980 knows what what’s the chicken and what
00:30:39.539 the what’s the egg there but he had a
00:30:41.460 huge change in his physiology glucose
00:30:44.340 went from being quite high he had
00:30:46.860 and he tracks all of this of course it’s
00:30:48.960 like
00:30:49.940 Jupiter after all right and retired I
00:30:53.039 suppose might have had and he’s retired
00:30:54.600 but he is he’s got the longest time
00:30:57.179 series of anyone I know
00:30:59.820 and he’s tracked his glucose and Insulin
00:31:02.100 going back 20 years
00:31:03.960 so he can show you okay here’s where I
00:31:07.020 started having my smoothie
00:31:08.820 and here’s how my glucose and Insulin
00:31:11.159 changed as a result of that I’d like to
00:31:13.380 take a quick break and acknowledge one
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00:31:20.580 mineral probiotic drink that covers all
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00:31:24.600 I’ve been taking athletic greens since
00:31:26.580 2012 so I’m delighted that they’re
00:31:28.740 sponsoring the podcast the reason I
00:31:30.419 started taking athletic greens and the
00:31:31.860 reason I still take athletic greens once
00:31:34.140 are usually twice a day is that it gets
00:31:36.600 to be the probiotics that I need for gut
00:31:38.580 health our gut is very important it’s
00:31:40.500 populated by gut microbiota that
00:31:43.080 communicate with the brain the immune
00:31:44.460 system and basically all the biological
00:31:46.200 systems of our body to strongly impact
00:31:48.179 our immediate and long-term health
00:31:50.520 and those probiotics and athletic greens
00:31:52.740 are optimal and vital for microbiotic
00:31:55.679 health in addition athletic greens
00:31:57.720 contains a number of adaptogens vitamins
00:31:59.460 and minerals that make sure that all of
00:32:01.080 my foundational nutritional needs are
00:32:02.760 met and it tastes great if you’d like to
00:32:05.760 try athletic greens you can go to
00:32:07.460 athleticgreens.com huberman and they’ll
00:32:10.559 give you five free travel packs that
00:32:12.240 make it really easy to mix up athletic
00:32:13.860 greens while you’re on the road in the
00:32:15.480 car on the plane Etc and they’ll give
00:32:17.520 you a year’s supply of vitamin d3k2
00:32:20.100 again that’s athleticgreens.com huberman
00:32:22.740 to get the five free travel packs and
00:32:24.600 the year supply of vitamin D3 K2 is
00:32:27.779 there a case for I’ll say young women
00:32:30.059 but young women and men using
00:32:32.940 over-the-counter probiotics as a way to
00:32:35.279 enhance the microbiome this is something
00:32:36.539 I hear about a lot I’ve heard that
00:32:37.919 excessive doses of capsule probiotics
00:32:39.960 can give a brain fog like condition
00:32:42.860 I personally don’t use capsule
00:32:45.059 probiotics unless I feel like my system
00:32:47.220 is under a significant amount of stress
00:32:49.080 in which case I might add that in for
00:32:50.520 brief periods of time or if I’ve just
00:32:52.260 taken antibiotics for a period of time
00:32:54.559 do you ever recommend that the college
00:32:57.059 student or the high school student that
00:32:59.520 she or he take capsule probiotics
00:33:02.120 assuming that they’re getting let’s say
00:33:04.620 three to five servings of vegetables per
00:33:06.840 day either in smoothie form or some
00:33:08.940 other form what are your thoughts on on
00:33:11.520 supplementing probiotics
00:33:13.799 it sounds like such a simple question it
00:33:16.740 is such a complex answer and I don’t
00:33:18.899 think we really have the answer so I’ll
00:33:21.120 tell you the way that I approach it
00:33:22.919 I look for randomized trials to support
00:33:25.019 my use of probiotics and frankly I’m
00:33:28.140 underwhelmed
00:33:29.519 so I’ve seen some data
00:33:31.559 if I invoke my
00:33:33.659 um NBA players for a moment
00:33:36.600 almost every player I’ve tested has
00:33:38.820 increased intestinal permeability they
00:33:40.620 just have such a high training load
00:33:42.299 probably mediated by cortisol very high
00:33:45.360 glucosis when they drain that they have
00:33:48.179 increased intestinal permeability so
00:33:50.279 those tight junctions in their intestine
00:33:52.740 become loose they develop a lot of
00:33:54.960 inflammation as a result of that and
00:33:56.940 when you’re a professional MBA player
00:33:58.740 and you’re making 20 million a year
00:34:01.380 like you don’t want a lot of
00:34:02.700 inflammation you want a little bit to
00:34:04.380 like help your muscles recover but you
00:34:06.120 don’t want it to be
00:34:08.399 um adding to problems when you develop
00:34:10.139 an injury so this is leaky gut leaky gut
00:34:12.899 yeah I don’t love that term but yeah
00:34:15.418 we’ll use it here so there’s a there’s a
00:34:18.359 particular
00:34:19.560 probiotic that is helpful in athletes
00:34:22.440 with leaky gut so that’s the kind of
00:34:24.418 specificity and randomized trial that
00:34:26.460 I’m looking for
00:34:27.899 the rest of it
00:34:31.260 I think there’s support if you find help
00:34:33.599 from it as you described if you take a
00:34:36.599 course of antibiotics I mean first of
00:34:38.219 all I would question whether you need
00:34:39.480 them but I try and avoid them there have
00:34:42.060 been instances where they’ve been
00:34:43.320 prescribed and I took them mostly in the
00:34:44.760 past I was in college they seem like
00:34:46.199 they kind of gave them out you had a
00:34:47.339 sinus infection to give you Pro you know
00:34:48.839 antibiotics using like yeah the worst
00:34:51.119 treatment ever yeah so if you’re coming
00:34:53.820 off of antibiotics I think that’s a good
00:34:55.500 time to do what we call replacement dose
00:34:57.540 probiotics I think what’s far more
00:34:59.940 interesting is
00:35:02.480 prebiotics I think the data is much
00:35:05.400 better for prebiotics and
00:35:08.580 um a selective use of polyphenols
00:35:12.780 how would a person in their teens and
00:35:15.180 20s or any age for that matter know
00:35:18.540 what whether or not they have
00:35:19.740 nutritional deficiencies what is the
00:35:21.420 best way to analyze if one is getting
00:35:23.339 enough magnesium and for that matter
00:35:25.859 what is going to be the best way to test
00:35:27.599 the microbiome you said stool sample and
00:35:31.079 I’ll come right back with the same
00:35:32.640 question I asked about a blood test
00:35:35.400 what time of day when during the month
00:35:39.000 um to establish a baseline so this would
00:35:41.520 be prior to embarking on a you know 97
00:35:43.980 vegetables or how many years per day 57.
00:35:47.280 well I love the idea that you’re telling
00:35:49.560 us if I’m gathering correctly is that
00:35:51.540 yes there’s a case for probiotics but
00:35:53.040 for the typical person regardless of age
00:35:54.720 eating more vegetables or drinking more
00:35:57.359 vegetables as the case may be is going
00:35:59.520 to be beneficial for the gut microbiome
00:36:01.220 perhaps without the need to go test
00:36:03.300 whether or not one is making a certain
00:36:05.339 number of estrogen related metabolites
00:36:07.200 or not just that that’s a great starting
00:36:08.700 Place eat or consume more vegetables
00:36:12.180 um but if one wants to analyze their gut
00:36:14.460 microbiome are there good tests
00:36:16.079 available to the general public this has
00:36:17.760 been I’m not going to name companies but
00:36:19.200 I’ve been tracking this over the years
00:36:20.820 and it’s never been clear to me that we
00:36:22.440 know what constituents of the gut
00:36:24.839 microbiome are are best we know that
00:36:27.300 dysbiosis is bad yeah and we know that
00:36:29.820 diversity of the microbiome is good we
00:36:31.800 hear this yeah but no one’s ever told me
00:36:33.480 that you want a particular ratio of one
00:36:37.079 microbiota to another right in a way
00:36:39.359 that has made any sense to me at least
00:36:40.980 totally I’m not a microbiologist but
00:36:43.500 whereas with you know with testosterone
00:36:46.260 in men we hear okay you want your free
00:36:47.820 testosterone to be about two percent of
00:36:49.320 your total perhaps with women you women
00:36:52.260 are gonna have more testosterone than
00:36:53.400 estrogen on average but still less than
00:36:55.380 men when you look at testosterone etc
00:36:57.960 etc but you can kind of get some some
00:36:59.640 crude measures but for the microbiome it
00:37:01.380 just seems like long lists of microbiota
00:37:03.540 for which I just get dizzy I just if you
00:37:06.300 just wrote out a bunch of I’s and L’s
00:37:07.800 and s’s you’d you can go halfway a bit
00:37:11.160 bit the same information I’m not trying
00:37:13.079 to poke at that field it’s a beautiful
00:37:14.400 field but they haven’t told me what to
00:37:16.500 what I what my microbiota ought to look
00:37:19.680 like like what’s a healthy microbiome
00:37:21.359 chart well that’s because we don’t know
00:37:24.480 I mean the best we have is Rob Knight’s
00:37:26.520 work but even that is limited in terms
00:37:29.880 of you know can I tell you that a a
00:37:32.460 woman in her 20s should have this
00:37:34.320 particular pattern with her microbiome
00:37:36.660 no I can’t so
00:37:39.420 um let me go to your first question
00:37:40.619 because I think you just asked about six
00:37:43.320 your first question is about nutritional
00:37:45.240 testing
00:37:46.260 what I like to do with nutritional
00:37:48.359 testing is run a panel that’s looking at
00:37:53.839 antioxidants so like vitamin A vitamin C
00:37:56.640 alpha lipoic acid
00:37:59.579 um plant-based antioxidants because you
00:38:01.200 can measure that in the blood
00:38:02.820 I like to look at some of the key
00:38:05.720 vitamins especially the B vitamin range
00:38:08.820 because as you probably know if you’ve
00:38:10.920 got a particular genetic
00:38:13.800 um polymorphism so you might be less
00:38:15.660 likely to be absorbing the right level
00:38:17.820 of vitamin B9 folate vitamin B12 Etc
00:38:22.260 I’m also looking going back to the
00:38:24.119 antioxidants at glutathione because I
00:38:26.040 think that’s such an important lever
00:38:27.480 when it comes to detoxification which we
00:38:29.940 haven’t talked about yet
00:38:31.380 and then I’m looking at some of the
00:38:32.940 Minerals Magnesium is really the most
00:38:34.800 important and we know that somewhere
00:38:36.300 around 788 of Americans are deficient in
00:38:38.880 magnesium that’s like the the lowest
00:38:40.980 hanging fruit I would be curious for
00:38:42.780 instance like with magnesium if that
00:38:44.760 number of people are deficient does that
00:38:46.920 mean that that number of people should
00:38:48.240 be targeting their nutrition towards
00:38:50.220 foods that contain magnesium and or
00:38:51.839 supplementing with magnesium and if so
00:38:53.880 what forms of magnesium we’ve talked
00:38:56.220 about mag three and eight for Sleep
00:38:58.079 there’s a Mexican there’s so many forms
00:39:00.119 it can be a little bit overwhelming to
00:39:01.560 people so any any detail in sourcing
00:39:04.079 would appreciate it great so first in
00:39:06.720 terms of testing what I prefer to do
00:39:10.079 is to mention one more than one lab and
00:39:12.720 more than one brand
00:39:14.820 um and I can just I’m speaking mostly
00:39:16.859 from experience so uh for testing I do a
00:39:21.000 lot of Genova neutrals
00:39:24.180 during the pandemic they developed an
00:39:27.240 at-home test normally with a neutral
00:39:29.160 valve you have to get your blood drawn
00:39:30.359 and you have to do a urine sample
00:39:32.460 so a lot of people can’t do that the
00:39:34.440 great thing about this test is your
00:39:36.359 insurance usually pays for most of it
00:39:38.520 and so the copay is about 150 dollars
00:39:42.240 so during the pandemic they developed
00:39:44.040 another test called metabolomics which
00:39:46.500 does much of the same testing but it’s a
00:39:49.200 finger prick
00:39:50.760 so most of my patients prefer that in
00:39:53.339 fact they haven’t gone back to the
00:39:54.480 nutribal
00:39:55.920 second lab is spectracell
00:39:58.980 I use Spectra cell occasionally I find
00:40:01.440 it not quite as easy in terms of fitting
00:40:03.780 into my practice but I’ve got friends
00:40:06.300 and mentors like Mark Houston who does a
00:40:09.660 lot of
00:40:11.040 kind of Precision
00:40:13.640 cardiometabolic Health he thinks
00:40:16.079 spectrosol is the best test out there so
00:40:19.140 you asked about magnesium
00:40:21.119 you have to measure red blood cell
00:40:22.740 magnesium like whole blood
00:40:25.260 and with deficiency it’s interesting
00:40:28.740 with
00:40:29.880 supplementation
00:40:31.560 for my patients who tend toward
00:40:33.420 constipation
00:40:34.859 and that’s frankly about 80 percent of
00:40:36.780 the women that I take care of really yes
00:40:39.359 wow I’d be curious as to why that that
00:40:42.000 is
00:40:42.839 um is it I I can guess diet stress
00:40:47.339 um patriarchy
00:40:49.140 rage
00:40:50.820 to psychosis so Pine the um the pine
00:40:55.020 system right
00:40:56.480 psychology Immunology neural and
00:40:59.520 endocrine factors combined is that yes
00:41:01.859 and then I would say there’s another
00:41:03.240 Factor
00:41:04.800 which is
00:41:08.520 being female is a health hazard
00:41:11.940 so we have twice the rate of depression
00:41:14.760 insomnia
00:41:16.440 we’ve got three to four x increased risk
00:41:19.320 of multiple sclerosis
00:41:21.060 we’ve got five to eight times the risk
00:41:23.579 of thyroid dysfunction
00:41:26.220 so if you just look at that and you look
00:41:28.200 at subtle pre-clinical thyroid
00:41:30.780 dysfunction
00:41:31.859 a huge number of the women that I take
00:41:34.020 care of well let me back off
00:41:35.820 a large number of the women that I take
00:41:37.680 care of have thyroid dysfunction that’s
00:41:40.320 contributing to constipation and if we
00:41:43.320 go back to that control system the
00:41:44.820 hypothalamic pituitary adrenal thyroid
00:41:46.619 Canal gut axis
00:41:48.900 and they have a lot of perceived stress
00:41:51.900 together with this borderline thyroid
00:41:54.060 function that no mainstream medicine
00:41:56.220 doctor has told her is a problem and
00:41:58.800 then she’s got a problem with the Tango
00:42:00.480 between estrogen and progesterone
00:42:04.260 she’s going to tend toward constipation
00:42:06.060 women have a lot more constipation than
00:42:07.740 men
00:42:08.579 the gut is about 10 feet longer in women
00:42:11.099 compared to men
00:42:12.720 we should talk about some sex and gender
00:42:14.579 differences and Define those sure and
00:42:16.920 they are much more likely to have a
00:42:18.480 torturous colon
00:42:21.000 and the way you know that is you get a
00:42:22.800 colonoscopy and they tell you
00:42:25.079 yeah it’s really hard to like get in
00:42:27.180 there and do what we need to do as a
00:42:29.400 brief tangent but I think this is the
00:42:30.900 time to ask
00:42:31.980 um at what age now do Physicians insist
00:42:36.000 their female patients get colonoscopies
00:42:38.760 for men I think the age used to be 50
00:42:41.099 now it’s getting ratcheted back to 45 or
00:42:44.099 40. again these are recommendations not
00:42:46.320 requirements but they’re pretty strong
00:42:47.700 recommendations from depending on where
00:42:49.680 you live Etc
00:42:51.660 um for women how early do you think they
00:42:53.760 should get a colonoscopy to to explore
00:42:55.920 for possible polyps and or colon cancer
00:42:59.400 yeah it’s a really good question I don’t
00:43:01.260 know the answer so what I’ve always
00:43:02.940 operated with is 50. the way that I
00:43:05.579 answer that is to go to the U.S
00:43:07.500 preventive task force rating to
00:43:09.780 determine based on their synthesis of
00:43:12.119 the data what age is the most
00:43:13.859 appropriate has it changed as you just
00:43:16.079 described for men from 50 to younger I
00:43:19.140 don’t know so we should fact check that
00:43:21.359 all these um additional health hazards
00:43:24.660 for women
00:43:26.339 um you mentioned some of the
00:43:28.200 you broadly mentioned psychological
00:43:30.300 impact right and of course these things
00:43:32.280 are all related psychology immunology
00:43:34.500 and one of the I think wonderful things
00:43:36.119 about
00:43:37.500 neuroscience and Science in general and
00:43:39.839 medicine is that there’s now an
00:43:41.700 understanding that all the organs are
00:43:43.200 connected to one another it’s a network
00:43:45.060 it’s a network and that the microbiome
00:43:47.099 sits at had um at a key node within that
00:43:50.339 Network
00:43:51.900 um and I think most people accept that
00:43:53.700 now yes yeah that seems to be a theme
00:43:56.160 that at least in the last 10 years is
00:43:57.780 really wonderful because
00:43:59.640 um certainly for Neuroscience it was
00:44:00.960 thought that you know unless it’s in the
00:44:02.400 cranial vault
00:44:03.720 it’s not neural which is ridiculous
00:44:05.880 because there’s lots of nervous system
00:44:07.020 outside the skull but in any case can I
00:44:10.380 interrupt for a second yes please so I
00:44:12.000 think you’re right that there’s an
00:44:13.619 understanding about the network effect
00:44:16.260 but I think that
00:44:18.359 as much as I love mainstream medicine
00:44:21.119 and I trained in it and I’m so grateful
00:44:24.000 for my education I still think it is a
00:44:26.760 silo based way of taking care of
00:44:28.500 patients so even if there’s an
00:44:30.240 understanding of the network effect more
00:44:31.920 at the science level or as you described
00:44:34.440 in Neuroscience there’s still you know
00:44:37.619 if you are a woman who has constipation
00:44:40.980 fatigue
00:44:43.260 um
00:44:44.099 maybe an autoimmune condition
00:44:46.880 feel stressed out all the time feel like
00:44:49.859 your hormones are out of whack you get
00:44:51.720 sent to the gastroenterologist for the
00:44:54.359 constipation you get sent to the
00:44:57.000 rheumatologist for your autoimmune
00:44:58.859 issues you maybe get sent to an
00:45:01.140 endocrinologist if you’ve got thyroid
00:45:03.599 problems and there’s very little
00:45:05.780 collaboration between these groups so
00:45:09.180 even though there’s an understanding of
00:45:10.920 the network effect
00:45:12.839 in real life it’s not happening
00:45:16.280 let’s um let’s go deeper down that path
00:45:19.920 because I you point out something really
00:45:21.300 important and you’ve mentioned
00:45:22.619 constipation a few times can we view
00:45:25.200 constipation as a serious enough symptom
00:45:27.240 that it warrants an immediate
00:45:28.740 intervention that is does it flag or
00:45:30.960 signal
00:45:32.520 problems that are severe enough that
00:45:34.079 that should be the issue that’s dealt
00:45:35.640 with uh for anybody that’s experiencing
00:45:38.040 it yeah and I mean sort of an odd topic
00:45:40.079 for many people because they think oh
00:45:41.099 you know bowel movements and sort of you
00:45:42.960 know there’s that kind of um
00:45:44.099 pre-adolescent humor around this but I
00:45:45.960 think it’s it’s so important when you’re
00:45:47.280 what I’m hearing you say is that
00:45:48.720 constipation is far more common in women
00:45:51.240 and it signals a general many problems
00:45:54.359 occurring does that mean that women
00:45:56.940 should address constipation and if so
00:45:59.099 what’s the best way to address
00:46:00.300 constipation yeah I love this question
00:46:02.700 because
00:46:03.900 you’re doing can we have a quick little
00:46:06.480 meta conversation so you’re doing
00:46:08.280 something that I knew you would do which
00:46:10.680 is
00:46:11.640 you’re teaching me something and you’re
00:46:13.680 changing like there’s a social genomics
00:46:15.540 thing happening where you’re changing my
00:46:17.220 thought about this so I just wanted to
00:46:19.079 acknowledge that thank you thank you
00:46:20.400 well I think for me you know when I hear
00:46:22.680 that there’s a kind of you know you’re
00:46:24.180 talking about a phenotype constipation
00:46:25.800 is a phenotype it’s one that people
00:46:27.599 generally don’t wear a t-shirt
00:46:28.920 explaining it to people but that I’m
00:46:30.839 guessing anything to do with sexual
00:46:32.760 health
00:46:33.540 um bowel Health Urology people just
00:46:36.780 don’t talk about right
00:46:38.700 um for all sorts of reasons and those
00:46:40.619 reasons are probably so obvious that
00:46:42.300 they’re not even worth discussing but
00:46:43.740 because and also because we won’t change
00:46:45.240 them except by talking about them yep so
00:46:48.000 if you say
00:46:49.680 um women are far more constipated and
00:46:51.960 that’s signaling a larger set of
00:46:53.579 problems yes then my immediate thought
00:46:55.560 is well will relieving constipation
00:46:59.099 um pun uh intended retroactively
00:47:02.640 um will that assist in a great number of
00:47:06.839 issues and or will it get them down the
00:47:08.880 road of thinking about those other
00:47:10.140 issues more specifically like do I need
00:47:11.760 more magnesium or should I be putting
00:47:13.440 vegetables in my smoothie you know so
00:47:15.240 I’m curious about constipation as a
00:47:17.339 Target yeah for intervention that then
00:47:19.740 opens up a bunch of other discussions
00:47:21.540 because there are these certain nodes in
00:47:23.099 the in the mental health physical health
00:47:25.020 space that when someone you know like we
00:47:27.660 talk a lot of deliberate cold exposure
00:47:29.400 do I think it’s magic no but I think
00:47:31.020 that if someone’s getting themselves
00:47:32.099 into a cold shower once a day it opens
00:47:34.260 up a nun a number of questions about
00:47:35.940 themselves and reveals a number of
00:47:37.380 things to themselves like how do I
00:47:39.000 buffer stress yeah what sorts of levels
00:47:41.339 of control do I actually have and on and
00:47:43.079 on so perhaps not the best example but
00:47:45.660 some of us hate cold exposure right
00:47:48.180 which is we have we have like a gene
00:47:50.099 that makes us stress out like you
00:47:52.079 wouldn’t believe which I would argue
00:47:54.180 makes it
00:47:55.260 um very likely that even 10 seconds of
00:47:57.540 cold exposure gets you the effect that
00:47:59.339 you want as opposed to someone who
00:48:00.780 adores cold exposure like a penguin
00:48:02.460 needs a lot more cold exposure for it to
00:48:04.380 have the the Adaptive response anyway
00:48:06.119 that’s my way of gumbing through that uh
00:48:09.359 quite uh you’re you’re quite correct
00:48:12.119 um so so let’s answer those questions
00:48:14.220 constipation issue yeah so this is how
00:48:16.800 you’re changing the way I think about
00:48:18.300 this
00:48:19.200 so you’re asking okay instead of looking
00:48:21.480 at constipation as a constellation of
00:48:23.880 symptoms what about if you just used it
00:48:25.920 on its own as sort of a
00:48:28.859 um
00:48:29.880 a key
00:48:32.040 indicator or signal
00:48:34.500 of dysfunction with my network or maybe
00:48:37.200 something broader
00:48:38.700 and I think that’s right
00:48:41.400 so it makes me think of a few things it
00:48:43.619 makes me you’re also changing this book
00:48:45.540 that I’m writing on autoimmunity and
00:48:47.460 Trauma so thank you for that so
00:48:51.300 women experience more trauma than men
00:48:53.220 this is well established if you look at
00:48:55.260 the ace studies that were done by the
00:48:57.540 CDC in Kaiser in 1998 we know that men
00:49:01.500 for the most part middle-aged men have
00:49:03.240 about
00:49:04.800 um
00:49:05.819 about 50 of them experience significant
00:49:09.119 trauma as defined by the ace
00:49:10.859 questionnaire women are at 60 and that’s
00:49:13.740 pretty durable since 1998. so women have
00:49:16.859 more they have different forms of abuse
00:49:20.040 much more likely to have sexual abuse
00:49:23.099 they have a different HPA response than
00:49:26.700 men
00:49:28.200 their perceived stress tends to be
00:49:30.599 higher and I’m generalizing for a
00:49:32.280 population
00:49:34.440 side note you know in Precision medicine
00:49:36.240 we don’t do that we do medicine for the
00:49:37.980 individual individual not the population
00:49:39.599 not medicine for the average
00:49:42.300 and so if you look at
00:49:44.880 the physiology of a female
00:49:47.579 I think that constipation and that need
00:49:51.060 to like control and restrain and hold
00:49:53.760 things in
00:49:55.560 you know tighten the anal sphincter
00:49:57.900 I think that’s part of the physiology
00:50:00.300 so I’m veering away from the science but
00:50:02.460 I do think that it is a really important
00:50:05.280 signal to pay a lot of attention to now
00:50:08.579 you also asked about microbiome testing
00:50:10.680 should we do that or do yeah well I have
00:50:12.839 a couple more questions about
00:50:13.560 constipation I never thought I’d ask
00:50:15.180 this many questions about concentrating
00:50:16.380 but now I’m fascinated by the way also
00:50:18.240 this morning I taught medical students
00:50:19.500 at Stanford about the fact that we are
00:50:20.760 basically a series of tubes so you
00:50:22.319 talked about the the anal sphincter we
00:50:23.940 are a set of sphincters from one end to
00:50:25.680 the other I mean we are a set of tubes a
00:50:27.599 nervous system being one of those tubes
00:50:29.160 and well and I think in eastern medicine
00:50:31.020 they talk about the various locks
00:50:32.520 between those tubes and Chambers and
00:50:34.140 it’s not without coincidence there’s
00:50:36.180 some real wisdom there of course wait
00:50:38.099 did you just talk about energetic
00:50:40.200 Anatomy uh more or less I didn’t say the
00:50:42.119 word chakras but uh but I might in
00:50:44.400 passage it’s the bondas right are the
00:50:47.220 are the are the the sphincters yes yes
00:50:49.800 that’s right uh thank you for for that
00:50:51.839 the um so what defines constipation I
00:50:55.380 mean in other words let’s think about
00:50:56.700 the healthy rather than thinking about
00:50:57.900 the unhealthy let’s how many bowel
00:51:00.180 movements should a woman or a man have
00:51:04.200 per day assuming this is where it gets
00:51:07.020 tricky because some people are doing
00:51:08.160 time restricted feeding some people are
00:51:09.599 eating more some people eat more fiber
00:51:11.040 more bulk larger meal at the end of the
00:51:12.359 day a larger meal the beginning of the
00:51:13.440 day we will never
00:51:15.180 um be able to sort out all those
00:51:16.500 variables but on average
00:51:19.920 um how many bowel movements and his
00:51:21.720 timing
00:51:22.859 during the day for bowel movements at
00:51:24.839 all informative what works for you
00:51:28.260 um well when I’m asleep
00:51:30.059 um generally I don’t want a bowel
00:51:31.319 movement so I’m going to be like most
00:51:32.640 people right well sleep is primary for
00:51:34.380 you right exactly um I always assumed
00:51:36.839 that morning time yeah was a was a
00:51:39.960 healthy time for bowel movements um and
00:51:43.500 I think almost everybody babies included
00:51:46.940 recognize the feeling of being lighter
00:51:49.859 and more energetic when they’ve
00:51:52.440 evacuated totally colon totally um in
00:51:54.839 fact so much so that I’m obsessed with
00:51:56.579 jungian and Freudian psychology that the
00:51:59.040 first thing we learn when we come into
00:52:00.119 this world right is that we want
00:52:01.500 something we we feel some sort of
00:52:04.319 autonomic arousal stress whether or not
00:52:06.599 it’s food or warmth or the need to have
00:52:09.059 a bowel movement one of the first things
00:52:10.260 that parents learn is how to recognize
00:52:12.059 that not by the odor coming from the
00:52:14.520 diaper but by the look on the baby’s
00:52:16.500 face or their agitation agitation
00:52:18.359 signals the need for some sort of relief
00:52:20.700 right temperature relief food relief
00:52:23.819 um evacuating the bowel relief so my
00:52:26.220 understanding is that as autonomic
00:52:27.780 arousal increases in the early part of
00:52:29.579 the day ideally after a good night’s
00:52:31.260 sleep that bowel movements become more
00:52:33.059 likely unless that arousal becomes so
00:52:34.920 great that then people feel so quote
00:52:37.020 unquote locked up right
00:52:38.819 um because of the balance of the
00:52:40.140 autonomics of features so early day I’m
00:52:43.680 guessing and again in the second half of
00:52:45.359 the day and here I’m totally guessing
00:52:47.700 um and certainly not having to wake in
00:52:49.140 the middle of the night
00:52:51.059 um yeah those are my best guesses
00:52:53.520 that’s great so I would agree with that
00:52:56.099 when I was at Harvard Medical School in
00:52:58.800 UCSF for residency I was taught that
00:53:00.960 constipation is having a bowel movement
00:53:03.480 less frequently than whenever once every
00:53:06.240 three days
00:53:08.040 so I don’t think I’ve ever laughed out
00:53:10.020 loud on this podcast as a consequence of
00:53:12.180 of uh textbook medical knowledge are you
00:53:14.520 kidding me is that ridiculous well that
00:53:16.380 sounds like and and here pun intended
00:53:18.000 that sounds like the uh the conclusion
00:53:20.640 of some very um constipated personally
00:53:23.400 and and and and in other ways
00:53:25.920 constipated individuals and again this
00:53:28.500 might seem like an odd conversation but
00:53:30.059 the the discussion around conservation
00:53:32.160 is is present in psychological
00:53:34.619 literature yes because of this
00:53:36.960 relationship to the autonomic system
00:53:38.520 well it’s a metaphor in literature
00:53:40.859 it’s crucial so you you spoke to a
00:53:44.160 number of different threads that I think
00:53:45.720 are important here so that’s the
00:53:47.640 definition that I learned and I was I
00:53:49.619 heard that and I was like hell no that
00:53:51.359 doesn’t work for me it doesn’t work for
00:53:52.980 anyone I know
00:53:54.660 and I spent a lot of time especially in
00:53:58.260 medical school and in my internship
00:54:00.180 where you rotate on medicine
00:54:02.660 disimpacting
00:54:04.319 women like older women who come in who
00:54:06.839 haven’t had a bowel movement in a month
00:54:08.720 whoa and that let me tell you that is
00:54:11.339 not nice for anybody yeah believe me I
00:54:13.859 became a scientist not a physician for a
00:54:15.960 number of reasons both positive and
00:54:18.119 negative that’s one of them yeah so my
00:54:21.480 definition of constipation as a western
00:54:25.220 mostly white girl
00:54:27.180 is that if you’re not having a bowel
00:54:30.240 movement every single morning and you
00:54:32.940 have a feeling of complete evacuation
00:54:36.300 anything less than that is constipation
00:54:39.660 so that’s how I Define it if you’re in
00:54:42.540 India and you’re eating food that’s got
00:54:45.960 a fair amount of microbes in it it’s
00:54:48.059 less you know sanitary I’m using that
00:54:51.119 word
00:54:52.859 um as carefully as I can
00:54:54.780 generally they have a bowel movement
00:54:56.940 after every meal
00:54:58.680 but they’ve got a different microbiome
00:55:00.359 they’re exposed to different microbes
00:55:01.859 here in the U.S I would say Wednesday
00:55:05.040 you also spoke to something very
00:55:07.500 important which is the balance between
00:55:10.500 the parasympathetic nervous system rest
00:55:13.319 and digest and poop versus the
00:55:16.260 sympathetic nervous system kind of the
00:55:17.819 on button you know
00:55:20.040 fight
00:55:21.180 flight freeze spawn
00:55:23.880 so I think for those of us who’ve got
00:55:27.660 issues with autonomic balance
00:55:31.920 it can lead to constipation and I like
00:55:34.680 that constipation could be pulled out
00:55:37.079 and kind of writ larger as an important
00:55:39.839 signal what sorts of tools do you
00:55:42.119 recommend people use to
00:55:44.579 um
00:55:45.420 relieve constipation
00:55:47.579 um in eating more fiber sounds like
00:55:49.920 reducing stress is going to be a huge
00:55:51.780 one yes what are your favorite stress
00:55:54.420 reduction tools
00:55:55.980 um I like to divide these into
00:55:58.160 real-time tools so a big proponent of
00:56:01.680 like physiological sign real time you
00:56:04.020 know these sorts of things but things
00:56:06.000 that can really lower the Baseline on
00:56:08.579 stress overall to facilitate
00:56:10.940 constipation and other other broad
00:56:14.579 indicators of Health
00:56:17.220 so I’m not a fan of lowering stress I’m
00:56:21.540 a fan of lowering perceived stress and I
00:56:24.119 think the distinction is really
00:56:25.260 important
00:56:27.480 I learned when I was in my 30s that
00:56:32.700 I was a massive stress case and I didn’t
00:56:34.980 know it it was just sort of
00:56:37.319 I think I through residency through
00:56:39.660 working 120 hours a week I just was so
00:56:41.760 accustomed and sort of
00:56:44.640 um that was 120 not under 20 folks yeah
00:56:47.940 not unusual in in medicine well they
00:56:50.819 they’ve changed training so that you
00:56:53.099 work no more than 80 hours a week now
00:56:55.079 but that was before my time
00:56:57.420 so
00:56:58.920 I became
00:57:01.579 accustomed to a massive amount of
00:57:04.800 cortisol massive
00:57:06.780 and
00:57:08.280 I would say I’ve spent the past 20 years
00:57:10.319 really working on perceived stress to
00:57:12.780 find I think all of us in all a cart
00:57:15.180 menu
00:57:16.260 of what is most effective
00:57:18.900 so what works for me now at my age is
00:57:22.140 different than you know the the TM I did
00:57:24.960 as a college student Transcendental
00:57:26.579 Meditation it’s different than the I
00:57:29.160 became a certified yoga teacher when I
00:57:30.660 was in my 30s that is very effective for
00:57:33.000 a lot of people
00:57:34.020 it wasn’t enough for my Matrix
00:57:37.440 I do holotropic breath work
00:57:40.920 um I didn’t read it but I saw it she
00:57:42.660 just had a paper and sell on your sign
00:57:44.579 and
00:57:46.859 um it kind of it made me think like
00:57:49.680 teach me how to teach teach me how to
00:57:51.960 sigh like can you say a little bit about
00:57:53.819 that like how do you do it yeah very
00:57:55.980 briefly that study was we we wanted to
00:57:57.839 find a minimal effective dose
00:57:59.460 intervention yeah I just wanted yeah so
00:58:01.859 five minutes a day we need to figure out
00:58:03.059 what people do every day yeah and we
00:58:04.800 were monitoring
00:58:06.300 subjective mood Etc but also Biometrics
00:58:08.940 remotely so it’s kind of a nice
00:58:10.440 Biometrics HRV HRV uh nighttime sleep
00:58:14.579 cortisol uh I wish
00:58:16.920 um so this was done during the pandemic
00:58:18.440 more than 100 subjects the advantage was
00:58:21.059 that we got data 24 hours a day because
00:58:23.220 they’re pinging us in their data uh
00:58:25.440 wearing HRV 24 yeah nice so that was
00:58:28.440 nice resting heart rate
00:58:30.359 um subjective mood we would get in touch
00:58:31.680 with them daily so when people were
00:58:34.559 swapped between groups like any good
00:58:36.059 study but five minutes a day of sort of
00:58:38.220 standard if you will forgive me
00:58:40.260 meditations are just sitting no
00:58:41.819 instructions about how to breathe just
00:58:43.200 focusing on
00:58:44.819 um closing their eyes and focusing on
00:58:46.559 focusing yep
00:58:48.599 um another group did box breathing yep
00:58:50.880 inhale hold exhale hold for equal
00:58:52.380 durations the duration of each of those
00:58:54.599 inhales and holds was set by their
00:58:56.700 carbon dioxide tolerance so somewhere
00:58:59.040 between three and eight seconds
00:59:01.319 depending on how well they regulate
00:59:02.880 carbon dioxide
00:59:04.260 another group did cyclic signs so this
00:59:07.260 would be double inhale through the nose
00:59:08.700 so big inhale through the nose
00:59:14.760 followed by it to lungs empty exhale
00:59:17.579 that second inhale after the first big
00:59:20.220 long inhale through the nose is really
00:59:21.540 important because it makes sure that all
00:59:23.339 the collapsed abiola the lungs totally
00:59:25.859 snap open and then the exhale you
00:59:27.420 offload a lot of carbon dioxide that’s
00:59:29.579 very similar to holotropic breath work
00:59:31.319 not yes not not
00:59:33.480 um not unlike holotropic breath we’re a
00:59:35.640 little bit pranayama-ish but the exhale
00:59:38.579 is rather passive as opposed to active
00:59:41.720 and then the fourth category was cyclic
00:59:44.160 hyperventilation which is a lot like
00:59:45.960 Tumo AKA Wim Hof ish breathing different
00:59:49.020 than Wim Hof breathing so this would be
00:59:51.780 so very active inhales and exhales
00:59:54.839 every 25 cycles of inhale exhale that’ll
00:59:57.420 be one cycle long exhale hold lungs
00:59:59.760 empty 15 to 30 seconds then repeat for
01:00:04.380 about five minutes now the info everyone
01:00:06.240 did that for five minutes and what we
01:00:07.740 found was that the cyclic sign led to
01:00:09.480 the greatest improvements in mood Around
01:00:11.640 the Clock not just around the the
01:00:13.500 practice or during the practice as well
01:00:15.480 as lowered resting heart rate
01:00:17.359 improvements in sleep
01:00:19.500 Etc and you got it publish and sell yeah
01:00:21.900 we were so amazing we’re very fortunate
01:00:23.700 I think um the the thankfully the
01:00:27.420 reviewers and editors understood that
01:00:28.980 these minimal intervention things uh
01:00:31.260 hopefully are going to be of use to
01:00:32.400 people so so useful to people I mean how
01:00:35.220 often do you read a paper like that that
01:00:37.680 could offer a behavior change
01:00:40.799 that is so easy to implement I mean I
01:00:43.920 love that question thank you so what
01:00:47.099 about did you tell them not to drink
01:00:49.200 because alcohol has such a huge effect
01:00:51.180 on HRV yeah so in this case we didn’t
01:00:53.040 tell them to alter anything else about
01:00:54.720 their behavior just hoping it was
01:00:56.099 background kind of across the system yes
01:00:58.980 and some were Stanford students others
01:01:00.599 were from the general population any
01:01:02.940 Frat Boys that were drinking heavily
01:01:05.339 probably not well during the pandemic I
01:01:07.440 think alcohol intake went way way up
01:01:09.900 across the board
01:01:11.460 um I mean isn’t if I had a magic wand I
01:01:13.380 would I would ask that people either not
01:01:14.940 drink or drink two drinks per week
01:01:16.740 maximum at least that’s my understanding
01:01:18.420 of the literature
01:01:19.980 um are you familiar with the whoop data
01:01:21.420 with alcohol no but we have a
01:01:23.460 collaboration with through that paper
01:01:24.960 yeah um and it certainly disrupts
01:01:27.240 patterns of nighttime sleep in
01:01:29.339 particular from my understanding that
01:01:31.260 first phase of sleep that’s related to
01:01:33.540 the massive growth hormone release that
01:01:35.280 you all really need and want in
01:01:37.260 different measure growth hormones we did
01:01:38.940 not no the second iteration of this
01:01:40.559 study will certainly include free
01:01:42.480 cortisol by saliva hormone panels well
01:01:45.240 I’m beginning to think that we should
01:01:46.319 also
01:01:47.400 um be asking people how often they’re
01:01:48.660 going to the bathroom and what time of
01:01:49.859 day yes I mean this thing around
01:01:51.480 constipation is uh is super interesting
01:01:54.000 and I think that plus um blood markers
01:01:56.760 and then I’m I’m very excited to learn
01:01:58.619 that
01:01:59.520 um that urine contains additional
01:02:01.859 markers that could be informative so
01:02:03.599 yeah it was it was a fun study uh not
01:02:06.240 easy study to do with that number of of
01:02:08.220 subjects um takes a lot of training for
01:02:10.859 your research assistants yeah it was a
01:02:12.839 big group it was nine people in our
01:02:14.099 group and three clinicians and a lot of
01:02:16.380 a lot of phone calls and a lot of back
01:02:18.000 and forth but you know and thank you to
01:02:19.799 the subjects who served as the uh the
01:02:21.780 real life guinea pigs so yeah I think
01:02:23.400 that stress you know people’s I think
01:02:25.680 people are starting to appreciate that
01:02:27.119 there are ways that they can relieve
01:02:28.380 their stress that that don’t only fall
01:02:30.960 under the categories of vacation right
01:02:33.359 and meditation but I want to say that
01:02:35.579 meditation is obviously a wonderful tool
01:02:38.520 um it’s just it’s a it’s a tool not
01:02:41.220 unlike any other tool that is great for
01:02:43.440 some people and less great for others
01:02:44.940 well certainly it’s a great tool and
01:02:46.559 it’s got such a scientific basis behind
01:02:48.540 it
01:02:49.319 but there’s so many things on this a la
01:02:51.720 carte menu sex orgasm
01:02:55.440 um connection
01:02:56.940 feeling heard and seen and loved
01:03:00.720 um yeah let’s talk about that you know
01:03:02.280 you mentioned earlier that all these
01:03:03.359 stress factors you you said patriarchy
01:03:05.400 right yeah but I think what if I may
01:03:08.339 um at risk of uh of just strengthening
01:03:11.700 that uh statement I I mean that that to
01:03:14.040 me is is signaling a bunch of other
01:03:16.440 factors around us you said like keeping
01:03:18.359 keeping things in
01:03:21.119 um
01:03:22.160 what do you think explains let’s talk
01:03:25.319 about that because I think that that’s
01:03:26.760 likely to have raised a certain flag in
01:03:28.380 people’s minds like what exactly is she
01:03:30.059 talking about are you talking about less
01:03:31.740 opportunity are you talking about less
01:03:33.660 opportunity to
01:03:35.700 um to vocalize are you talking about
01:03:37.740 less opportunity to vocalize and be
01:03:39.480 heard I mean I realize that there are an
01:03:41.099 infinite number of variables but given
01:03:42.780 that it sounds like a really strong
01:03:45.359 input to the system uh what I mean by
01:03:48.599 that is that psychology is influencing
01:03:50.819 biology and you’re saying that that
01:03:52.380 these uh
01:03:53.880 that these power power dynamics
01:03:57.140 structures and Dynamics are impacting
01:03:59.520 I’d love let’s hear your thoughts on
01:04:00.900 that because uh I I hate to let a flag
01:04:03.540 like that go by without fleshing it out
01:04:05.940 and never waste a good flag well and
01:04:07.859 let’s preface it by by just saying that
01:04:09.900 like people will have different opinions
01:04:11.339 on this and that’s and I think that’s
01:04:12.599 healthy and like with the discussion
01:04:14.220 about constipation let’s talk about what
01:04:15.780 people aren’t willing to talk about when
01:04:17.099 it comes to health love it so we might
01:04:20.220 need to talk about patriarchy on part
01:04:22.380 two but I’ll give you some material that
01:04:24.720 I’ve been working with
01:04:26.520 I started I did not even understand the
01:04:30.180 existence of patriarchy until I was a
01:04:32.640 bioengineering undergraduate at MIT I
01:04:35.579 should mention which has always had a
01:04:37.200 bit of a of a male
01:04:39.900 um askewed male in terms of Faculty
01:04:42.059 numbers well my my that’s true at most
01:04:44.460 universities true well my postdoc
01:04:45.900 advisor was the late Ben Barris who was
01:04:48.720 a female to male transition transgender
01:04:51.660 interest first transgender member in the
01:04:53.520 National Academy of Sciences were my
01:04:54.780 closest friends unfortunately he died of
01:04:56.400 of pancreatic cancer we were very very
01:04:58.500 close they’re actually making a
01:04:59.579 documentary about Ben but Ben this is
01:05:01.980 interesting Ben went to MIT because he
01:05:04.859 wanted to be around a lot of men yeah
01:05:06.780 that’s a lesser known fact but then he
01:05:08.579 was a very strong advocate for women he
01:05:11.819 went as Barbara when he was Barbara and
01:05:15.420 um by the way he’s given me permission
01:05:16.980 to share all this prior to his death I
01:05:19.020 recorded a lot of conversations yeah
01:05:21.660 um I only ever knew him as Ben by the
01:05:23.640 way but when he was at MIT he was
01:05:26.400 identified female and he later talked
01:05:30.420 about the intense
01:05:33.240 um
01:05:33.839 suppression oppression literally is how
01:05:36.119 he described it especially given that he
01:05:38.460 was performing so well yes so you just
01:05:41.460 defined patriarchy
01:05:43.260 you did it yourself
01:05:45.839 a couple things
01:05:47.819 when I was in bioengineering
01:05:51.059 I took a women’s studies class
01:05:53.099 and it was all about teaching
01:05:55.500 undergraduates about the existence of
01:05:57.599 patriarchy which I would Define maybe at
01:06:00.660 its simplest as power over
01:06:04.200 I’m not saying men are patriarchy I’m
01:06:06.900 saying something very different which is
01:06:08.640 power over
01:06:11.220 let me correct one thing that you said I
01:06:14.040 didn’t go to MIT as an undergraduate
01:06:16.380 so I’m from I was in Alaska and I went
01:06:19.559 to the University of Washington for
01:06:21.359 bioengineering in Seattle in Seattle
01:06:23.579 okay I dropped out of a graduate program
01:06:26.460 in bioengineering to go to the Harvard
01:06:29.880 MIT
01:06:31.440 program for Health Sciences and
01:06:33.420 technology in Boston thanks for that
01:06:36.000 clarification University of Washington
01:06:37.440 also wonderful place I have many many
01:06:39.780 many many many many many wonderful close
01:06:42.539 colleagues there it’s an incredible
01:06:43.980 place especially for vision science
01:06:46.200 it’s especially good for engineering
01:06:48.180 bioengineering but
01:06:50.640 um yeah so my my MD is jointly between
01:06:54.240 MIT and Harvard and it’s the oldest
01:06:57.839 maybe largest although Harvard says this
01:07:00.839 a lot program for biomedical engineers
01:07:03.920 and uh MD phds physician scientist
01:07:08.640 training program
01:07:10.319 great thanks for that clarification I’m
01:07:12.420 going to blame the internet for this one
01:07:13.920 I am I think we need to send our our
01:07:16.559 Wikipedia editors out there I think
01:07:18.660 LinkedIn is correct okay great well
01:07:20.880 Wikipedia editors note get out there and
01:07:24.299 make that make the correction now you
01:07:25.740 heard it
01:07:26.760 um so
01:07:28.319 stress that is what you’re really
01:07:30.180 talking about is systemic stress in the
01:07:32.099 body as a concept as a consequence
01:07:34.559 excuse me of systemic stress of
01:07:36.119 environment that’s right
01:07:38.819 you know there’s particular forms of it
01:07:40.559 I would say this also relates to
01:07:43.440 White Privilege it relates to
01:07:46.880 racism
01:07:48.839 and when you look at
01:07:50.940 you know kind of the way that systems
01:07:53.460 including my beloved MIT
01:07:56.400 the way that they’re set up is that
01:07:58.079 might make us makes right
01:08:00.059 and generally the people that are the
01:08:02.099 strongest
01:08:03.299 you know big men strong men they’re the
01:08:05.700 ones who tend to be the most successful
01:08:08.220 so for people who are bipoc for people
01:08:11.520 who don’t have white privilege for women
01:08:14.819 it’s a different experience and so I’m
01:08:17.279 using patriarchy as kind of a
01:08:19.738 umbrella here but it connects to many
01:08:23.339 other things
01:08:24.420 I’d like to take a brief break and thank
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01:08:39.960 done for the simple reason that many of
01:08:42.359 the factors that impact your immediate
01:08:43.920 and long-term Health can only be
01:08:45.660 analyzed from a quality blood test the
01:08:47.640 problem with a lot of blood and DNA
01:08:49.080 tests out there however is that you get
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01:08:53.640 and hormones and so forth but you don’t
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01:08:59.939 what sorts of nutritional behavioral
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01:09:07.380 in order to adjust the numbers of those
01:09:09.238 metabolic factors hormones lipids and
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01:09:25.198 that’s inside tracker.com huberman to
01:09:28.080 get twenty percent off I want to use
01:09:29.939 this as an opportunity to a keep this in
01:09:32.759 mind as I return to a question that I
01:09:35.939 didn’t close the hatch on earlier and
01:09:37.799 it’s my fault which is I’m now clear on
01:09:40.380 the fact that a woman in her late teens
01:09:43.439 early 20s ought to know something about
01:09:45.179 her testosterone estrogen thyroid
01:09:46.738 cortisol levels
01:09:48.779 should start at least thinking about her
01:09:50.399 microbiome
01:09:51.600 should be thinking about
01:09:54.299 how how many bowel movements and the
01:09:56.640 timing of those bowel movements per day
01:09:59.100 really and
01:10:01.500 I’m assuming that what I just described
01:10:03.900 is also true for women in their 20s 30s
01:10:07.199 40s 50s on up to hundreds is that
01:10:10.380 correct
01:10:11.520 that’s correct but I would say that
01:10:13.080 there are
01:10:15.780 differential opportunities
01:10:18.300 by decade
01:10:20.040 so I’m glad she circled it back to
01:10:22.460 teenagers and testosterone because I
01:10:25.260 think if you know
01:10:26.940 for instance in your teenage years that
01:10:31.140 you have high androgens and that you’ve
01:10:33.360 got this potential phenotype way into
01:10:35.880 the future that you may not even notice
01:10:37.320 I mean maybe you notice you’ve got a few
01:10:39.000 extra hairs on your chin or something
01:10:41.640 if you know that your testosterone is
01:10:43.620 elevated or some other androgen it might
01:10:46.380 change the Arc of how you take care of
01:10:48.239 yourself so I think that could be very
01:10:50.040 helpful in your teenage years in your
01:10:52.620 20s for people who are a stress case
01:10:55.260 like me so age 27 on the words at UCSF
01:11:00.780 if I had known that I was such a high
01:11:02.580 cortisol person
01:11:04.560 I think I would have done things
01:11:05.760 differently I would have changed my
01:11:07.380 behavior
01:11:08.520 and I don’t know because I didn’t base
01:11:10.920 case these but
01:11:13.080 your testosterone
01:11:15.179 can decline starting in your 20s kind of
01:11:18.060 depending on how much stress your Matrix
01:11:20.699 is under so for women that can start as
01:11:23.159 early as 28 usually your testosterone
01:11:26.100 declines by about one percent per year
01:11:28.380 what level of testosterone do you like
01:11:30.480 to see in a woman once she’s sort of
01:11:32.340 post let’s say after age 25 what kind of
01:11:34.980 range is healthy I know what the
01:11:36.300 reference range is only because I know
01:11:38.520 one could look it up I don’t know it’s
01:11:40.020 off the top of my head immediately but
01:11:42.360 what what’s a kind of a nice reference
01:11:45.960 point there so the way I tend to
01:11:48.060 describe this on podcasts is the top
01:11:50.640 half of the normal range great
01:11:53.280 so that I think is a good benchmark
01:11:55.920 you know for PCOS
01:11:58.800 generally it’s much higher than that you
01:12:01.320 know I’ve seen patients with PCOS where
01:12:03.300 their total testosterone is 100 to 200.
01:12:05.580 do they always have peripheral
01:12:06.960 manifestations of that a little bit of
01:12:08.640 hair the the skin plaques I’ve heard
01:12:10.620 about you know so darkened skin
01:12:11.699 irregular periods regular periods is
01:12:14.040 that
01:12:14.760 um you know I get a lot of questions
01:12:16.320 about PCOS yeah
01:12:18.360 um and you’re the first person we’ve had
01:12:20.940 on this podcast that’s really qualified
01:12:22.260 to talk about PCOS in a real way
01:12:25.140 um so here we’re talking about too many
01:12:26.760 androgens cysts on the ovary irregular
01:12:29.880 ovarian
01:12:31.219 excuse me I keep saying that ovulatory
01:12:33.540 slash menstrual cycle
01:12:36.179 um
01:12:36.960 what are some other indicators and do
01:12:39.900 you recommend that women start taking
01:12:42.120 Androgen blockers or so or I mean how do
01:12:45.000 seems to be a lot of PCOS out there I’m
01:12:46.980 hearing about it a lot
01:12:48.900 so glad you asked about this so PCOS is
01:12:51.719 one of those really
01:12:53.340 poorly understood conditions that gets
01:12:56.880 it kind of flows flies below the radar
01:12:59.040 until a woman wants to get pregnant or
01:13:01.800 she’s got some other issue that drives
01:13:03.900 her to a physician
01:13:06.120 the problem is that it is a syndrome
01:13:09.120 right so polycystic ovary syndrome
01:13:12.179 sometimes polycystic ovarian syndrome
01:13:15.120 and syndromes don’t necessarily fit
01:13:17.820 together into a really clear diagnostic
01:13:20.940 criteria
01:13:22.500 so in this instance there are three
01:13:25.380 different criteria that we look for so
01:13:27.300 this is on the ovaries having
01:13:30.060 um clinical manifestations of
01:13:32.540 hyperandrogenism so that could be
01:13:34.260 hirsutism acne other things and then
01:13:37.320 usually irregular periods and the way
01:13:39.659 that that’s defined at least by the uh
01:13:42.719 latest criteria is having a period every
01:13:45.239 35 days or less
01:13:47.640 so typical cycle length 28 is 35 days
01:13:50.699 you know you’re skipping a period here
01:13:52.320 and there
01:13:53.400 so those are the those are the criteria
01:13:55.440 that we use to diagnose PCOS there are
01:13:58.140 about four different systems out there
01:14:00.780 in the literature for diagnosing PCOS
01:14:02.820 which is where it starts to get
01:14:04.560 confusing so there’s some women who have
01:14:07.699 gnosis on their ovaries but they’ve got
01:14:10.500 hirsutism and they’ve got irregular
01:14:13.140 periods could you define haircitism here
01:14:15.600 statism is increased hair growth usually
01:14:17.820 in places that you don’t want it so for
01:14:20.040 women it can be you know kind of male
01:14:21.600 pattern they might notice it on their
01:14:22.980 breasts on their chest
01:14:25.500 um
01:14:26.280 and then there’s of course a familial
01:14:29.280 quality to that like I was just looking
01:14:31.020 at a paper last night looking at
01:14:32.719 Israelis and how much hair statism they
01:14:35.400 have and whether this is related to CH E
01:14:38.219 repeats on the Androgen receptor
01:14:40.560 do they get um not Israelis but um do
01:14:42.960 women who
01:14:44.219 um who might have PCOS experience um
01:14:46.860 androgenic alopecia so hair loss that’s
01:14:49.199 sort of of the quote-unquote male
01:14:51.000 pattern baldness of course it’s Androgen
01:14:52.860 pattern baldness as opposed to male
01:14:54.719 we’re talking about testosterone DHT
01:14:56.760 related sometimes you know this is where
01:14:59.400 I’m going to invoke clinical experience
01:15:01.080 rather than what I’ve seen in the
01:15:03.239 literature women definitely can have
01:15:05.460 some androgenic alopecia
01:15:08.760 I tend to see it later in life
01:15:11.520 but this is an important point because
01:15:13.380 we think of PCOS as you know I was just
01:15:16.260 talking about it in teenage years like
01:15:17.940 wouldn’t it be nice to know that you
01:15:19.860 have this phenotype and you’re at risk
01:15:21.659 for all the things that people are at
01:15:23.159 risk for and we haven’t talked about
01:15:24.239 glucose and Insulin yet we should
01:15:27.239 what we know is that
01:15:29.580 PCOS is not just a problem in terms of
01:15:32.280 irregular periods and then difficulty
01:15:34.920 getting pregnant so those are mostly
01:15:37.080 problems in your 20s 30s early 40s but
01:15:41.100 it is a massive risk factor for
01:15:44.340 cardiometabolic disease as you get older
01:15:47.040 so many people tend to pigeonhole PCOS
01:15:50.340 is a problem of reproductive age we have
01:15:52.860 to be thinking of it over the entire
01:15:54.540 female life cycle and I would say it’s
01:15:57.840 even more important to consider it over
01:16:00.600 the age of 50 you know average age of
01:16:02.280 menopause is 51-52 because we know that
01:16:06.179 that elevated testosterone the high
01:16:08.100 androgens
01:16:09.480 are probably the greatest cardio
01:16:12.000 metabolic driver of disease for women
01:16:15.540 with PCOS wow now one other thing I want
01:16:18.300 to mention and I still have my notes
01:16:20.640 that we’re going to talk about
01:16:21.239 microbiome testing because that’s such a
01:16:22.920 fun subject
01:16:26.100 what I was taught to do
01:16:28.140 again saying this was so much love for
01:16:30.300 the people who have taught me how to do
01:16:31.800 medicine what I was taught to do is that
01:16:34.199 if you have a woman with PCOS you make
01:16:36.000 the diagnosis you measure her
01:16:37.500 testosterone you see if she has acne
01:16:39.300 blah blah
01:16:41.580 you ask that woman one question
01:16:45.540 do you want to get pregnant or not
01:16:48.300 so then you have these women with PCOS
01:16:50.400 who get started on a birth control pill
01:16:52.500 if they don’t want to get pregnant if
01:16:54.719 they want to get pregnant then you help
01:16:56.580 them get pregnant by addressing some of
01:16:58.920 these PCOS issues like maybe you give
01:17:00.780 them Clomid or you do something to make
01:17:03.120 them ovulate more frequently
01:17:05.400 that is the way that most conventional
01:17:07.800 medicine approaches this and it does
01:17:09.540 women at gigantic disservice so one of
01:17:11.820 the things I’m speaking into is the
01:17:13.800 gender gap that exists so I my feeling
01:17:18.239 is that the research money that goes
01:17:21.000 into women’s health is abysmal compared
01:17:23.699 to what goes into mental health really
01:17:25.620 and I think that’s changing but there’s
01:17:27.719 also a huge lack of awareness of sex and
01:17:30.420 gender differences when it comes to the
01:17:32.159 way that we construct
01:17:33.900 clinical trials and other experiments
01:17:36.300 well that’s absolutely true I mean I sit
01:17:37.860 on I’ve sat on NIH review panels for
01:17:40.140 more than a decade now I’m a regular
01:17:41.880 standing member which is only to say
01:17:43.140 that I see the research as it’s being
01:17:45.120 proposed yes and now
01:17:48.060 it’s required no Grant will get funded
01:17:50.760 without
01:17:51.719 sex as a biological variable and here
01:17:53.640 I’m by the way folks this is sex
01:17:55.640 biological sex the noun not sex the verb
01:17:58.620 both are super interesting obviously but
01:18:01.440 um when we say sex is a biological
01:18:02.820 variable meaning even if it’s a study on
01:18:05.400 mice how did that start though that
01:18:07.679 didn’t start that long ago it must have
01:18:08.940 been I think we can think
01:18:11.040 I don’t want to miss attribute here I
01:18:12.420 think we can thank Francis Collins for
01:18:13.920 insisting on this amen Francis
01:18:16.340 Bernadine Healy has done so much to help
01:18:19.080 us but you know she made the Women’s
01:18:21.719 Health Initiative which I hope will get
01:18:23.340 to
01:18:24.480 which is a hot mess like so confusing
01:18:26.820 the data that came out of that yeah so
01:18:29.040 and these trials are long and so the
01:18:30.480 data are only now starting to emerge so
01:18:32.460 just to be clear I mean I have a a
01:18:34.739 question that I don’t think is going to
01:18:36.120 take us off track but this is I’m going
01:18:37.500 to pose this question as a hypothesis
01:18:39.060 because I think it’s likely to be a
01:18:41.580 little bit of a of a not a barbed wire
01:18:44.400 question but maybe like a prickly
01:18:46.199 question when people first hear it but
01:18:48.120 it’s posed as a hypothesis you mentioned
01:18:50.400 some of the psychosocial stress issues
01:18:52.640 based on at the organizational level
01:18:55.440 institutional level societal level maybe
01:18:57.480 right down to the family and and just
01:19:00.120 life that are biasing Health outcomes
01:19:03.600 for the worse in female populations okay
01:19:06.179 you refer to as the patriarchy I’m just
01:19:08.159 trying to put it make sure that we’re
01:19:10.020 both talking about the same thing and
01:19:11.400 that’s non-exhaustive I realize that’s
01:19:13.440 just a subset of the issues
01:19:15.780 I’m also hearing there’s a lot more PCOS
01:19:18.199 which is hyper androgenization of the
01:19:22.620 ovary in there we’re talking about you
01:19:25.800 mentioned you know excess testosterone
01:19:27.540 which females naturally have more
01:19:29.880 testosterone than they do estrogen
01:19:31.440 anyway but we’re talking about elevated
01:19:33.540 levels
01:19:35.159 here’s a hypothesis one hypothesis would
01:19:38.400 be that the increased androgens and the
01:19:41.219 pieceo PCOS are a consequence of the
01:19:44.580 psychosocial conditions that are
01:19:47.580 I don’t say forcing but are biasing the
01:19:50.219 need for females to
01:19:53.940 um think behave react act in certain
01:19:56.580 ways
01:19:57.500 to survive let alone Thrive is that a I
01:20:01.679 don’t say this for any kind of political
01:20:03.179 correctness hypothesis this is a in my
01:20:06.600 this would be a fun interesting and I
01:20:08.640 think important study to run right
01:20:10.219 depending on stress and the conditions
01:20:12.719 the specific
01:20:14.159 type of stress do females under produce
01:20:18.480 or over produce androgens or is it a
01:20:22.380 neutral effect does that make make sense
01:20:24.560 I love this question so let me just
01:20:27.780 paraphrase the last part of it to make
01:20:29.460 sure I got it
01:20:30.780 it sounds like what you’re asking is
01:20:33.719 could PCOS or at least some phenotypes
01:20:36.179 of PCOS be a response to what I’m
01:20:39.300 calling patriarchy
01:20:41.460 and then you add a second part to it
01:20:43.560 which is do healthy women
01:20:46.199 like what is their production of
01:20:47.580 testosterone like is that right yes and
01:20:49.679 and with the acknowledgment I mean
01:20:51.179 you’re the expert here
01:20:52.739 um you’re the physician clinician an
01:20:54.659 expert in hormones and I’m not but with
01:20:57.900 the understanding that absolute levels
01:20:59.880 of hormones are interesting but perhaps
01:21:01.820 not as interesting as the ratios of
01:21:04.440 testosterone to estrogen so when we’re
01:21:06.179 talking about excess testosterone we’re
01:21:07.980 really not talking about oh women making
01:21:09.480 a lot of testosterone because frankly
01:21:11.100 they already make a lot like then most
01:21:13.800 people that weren’t aware of that I
01:21:15.179 wasn’t aware that women make more
01:21:16.440 testosterone right and so it’s not
01:21:19.320 saying that testosterone in women is bad
01:21:21.000 or is always a reaction to the
01:21:22.320 environment yes but when it becomes
01:21:25.440 um super physiological or hyper elevated
01:21:28.159 is I could imagine all sorts of social
01:21:31.020 conditions that would create that so in
01:21:34.860 males and females but here we’re talking
01:21:36.659 about PCOS and females in particular so
01:21:38.580 I’d love for you to speculate
01:21:40.920 um should we run the study we should
01:21:42.480 totally run the study because
01:21:45.060 I don’t know the answer
01:21:47.400 I suspect that you’re onto something
01:21:51.060 it may not explain all of the women with
01:21:53.400 PCOS because as I mentioned there’s a
01:21:55.199 lot of different phenotypes but I think
01:21:57.360 it could explain
01:21:59.340 a significant portion
01:22:01.860 and you know you’re almost you’re saying
01:22:04.320 if we look at the gene environment
01:22:06.120 interface this environmental influence
01:22:09.060 of having being someone who’s got power
01:22:11.940 over you if if PCOS was a response to
01:22:15.420 that
01:22:16.980 the way that we treat it would be
01:22:19.380 completely different
01:22:21.840 so on the one hand I want to be careful
01:22:23.820 not to dismiss the suffering and
01:22:26.520 experience of women with PCOS I’ve got a
01:22:28.679 lot of women with PCOS in my family and
01:22:31.620 it is
01:22:34.020 there’s so much pain and suffering you
01:22:36.120 know especially if you want to have a
01:22:37.380 baby and you try for years and you just
01:22:40.199 can’t ovulate
01:22:43.980 on the other hand
01:22:47.520 I read a paper recently and maybe we
01:22:49.980 could cite this
01:22:51.360 that compares the phenotype of a woman
01:22:53.640 with PCOS to a man who is hypoandrogenic
01:22:58.380 and I think that’s a really interesting
01:23:00.719 way to look at this because
01:23:04.679 the thread we haven’t talked about with
01:23:06.360 PCOS is the the role of insulin and
01:23:09.840 glucose
01:23:11.159 so for some of the phenotypes of PCOS
01:23:15.480 the problem is hyper insulin emia High
01:23:18.179 insulin in the blood is driving those
01:23:20.340 thika cells and ovaries to overproduce
01:23:22.500 testosterone these women are insulin
01:23:24.480 insensitive so
01:23:25.920 more insulin is being cranked out
01:23:28.440 and these cells in the ovary are
01:23:30.000 therefore making more Androgen you don’t
01:23:31.980 like to say insulin resistant oh I I can
01:23:34.500 uh I don’t have a problem saying okay
01:23:36.920 I’m just a little bit outside the lane
01:23:39.480 lines of my expertise so I was trying to
01:23:41.100 use it what is the correct nomenclature
01:23:42.900 so that we can make sure well what I
01:23:44.580 like about insulin insensitive the way
01:23:46.199 that she just said it is that I think
01:23:48.060 that offers people a way in and I love
01:23:50.340 to do that in terms of messaging insulin
01:23:53.219 resistance starts to lose people because
01:23:55.140 they don’t really get what that means at
01:23:56.760 a receptor level I think I say insulin
01:23:58.800 insensitive because when people hear
01:24:01.020 insulin sensitive it almost sounds like
01:24:03.360 a bad thing but that’s actually what you
01:24:04.739 want so I think I think that’s how I
01:24:06.420 defaulted to insulin what’s your insulin
01:24:08.940 I don’t know what I’m due for a blood
01:24:11.159 test yes you are I’m due for a blood
01:24:12.900 test um I had blood work done for eight
01:24:15.060 months um sure that’d be great I uh I’m
01:24:17.880 always
01:24:18.659 um experimenting with different
01:24:19.500 supplements and different behavioral
01:24:21.179 regimens and I’ve kept charts since I
01:24:23.219 was 19. oh you’re like my patient I I’ve
01:24:26.159 been sort of Obsessed by this and I
01:24:27.780 would say
01:24:28.980 everybody if you can afford it and at
01:24:31.199 the time actually I had to save up
01:24:32.580 Insurance wouldn’t cover it
01:24:34.679 um get some basic blood work done so you
01:24:37.080 have a reference do it as soon as
01:24:38.640 possible because even you know the we’ve
01:24:41.400 been talking about these women over the
01:24:43.679 life cycle
01:24:44.940 I wish I knew what my insulin was when I
01:24:47.520 was a teenager I wish I wish I knew what
01:24:49.260 my fasting insulin was I really wish I
01:24:51.360 knew my postprandial insulin like in my
01:24:54.600 teenage years in my 20s in my 30s well I
01:24:57.540 knew it in my 30s starting at 35. are
01:24:59.940 you a fan of continuous glucose monitors
01:25:02.460 the hugest most gigantic fan of cgms
01:25:05.280 I’ve never seen any tool that I’ve ever
01:25:07.199 used in medicine change Behavior the way
01:25:10.020 that cgms do wow why do you think they
01:25:12.659 are so effective at changing Behavior
01:25:15.060 I’ve tried one and I really liked it I
01:25:16.980 learned that in the sauna my insulin or
01:25:19.860 my blood glucose goes up probably by a
01:25:21.480 bit of dehydration I learned what kind
01:25:22.980 of foods work for me which don’t
01:25:25.560 um I thought it was fascinating I
01:25:26.880 learned how every Behavior you could
01:25:28.260 possibly imagine use your imagination
01:25:30.000 impacts blood glucose totally totally
01:25:32.219 fascinating to me including how a
01:25:34.320 two-way wake-ups during the middle of
01:25:36.120 the night versus one versus none
01:25:37.560 impacted blood glucose the next morning
01:25:39.840 fascinating for a data junkie like me it
01:25:42.360 was like I was in heaven
01:25:44.520 um why do you think they are so
01:25:46.020 effective in changing behavior is it
01:25:47.460 because of that that people can see that
01:25:48.719 real-time control like scan in and like
01:25:51.000 oh that’s the that’s the sandwich I
01:25:53.580 think it’s I think it’s many things I
01:25:55.320 think it’s
01:25:57.540 generally the enchantment
01:25:59.940 of learning about your own chemistry and
01:26:02.219 biology I love it and I think for me
01:26:04.920 what I’ve seen you know I feel like
01:26:06.540 doctors are basically marketers
01:26:09.179 like the sacred marketing like our job
01:26:11.639 as a physician is to convince people
01:26:15.060 to do something that we think is good
01:26:16.739 for them based on the best science
01:26:19.380 but we can’t just say here I wanted to
01:26:21.840 fill this prescription for a ctm you
01:26:23.880 have to Market it you have to say
01:26:26.100 I think this completely changes the way
01:26:29.400 that you approach your pre-diabetes I
01:26:31.260 think this could dramatically affect
01:26:33.840 your risk of Alzheimer’s disease that
01:26:36.000 you’re so worried about that your mother
01:26:37.380 has so our job as Physicians is to be
01:26:40.679 that sacred marketer
01:26:42.480 so cgms are one of my tools that I think
01:26:45.060 are so crucial so enchantment number two
01:26:47.820 yeah it’s the real-time effect
01:26:50.280 so if you go get your glucose and
01:26:52.440 Insulin measured or maybe you do like a
01:26:54.420 two hour glucose challenge test where
01:26:56.699 you look at glucose and Insulin at the
01:26:59.100 fasting point one hour later two hours
01:27:00.840 later or more frequently
01:27:03.000 that does not have the same kind of
01:27:05.340 behavior effect as having continuous
01:27:08.100 data where you can say okay I drove to
01:27:11.280 see you Andrew from my place in Berkeley
01:27:13.679 and it was stressful it was torrentially
01:27:16.820 raining and I know my glucose was
01:27:19.560 elevated like I think really
01:27:21.360 understanding
01:27:22.679 what the
01:27:24.480 the mediators are of your glucose
01:27:26.880 control is essential now that said
01:27:29.820 it’s also kind of a later effect I mean
01:27:31.860 I’d rather know your insulin and we know
01:27:34.380 from uh the white hat white Hall study
01:27:37.620 that insulin especially postprandial
01:27:40.620 insulin vascular insulin 2 can change
01:27:42.840 years and years before you get a change
01:27:45.540 in glucose
01:27:46.860 so um that’s more for pre-diabetes and
01:27:50.280 diabetes so I think those are the main
01:27:52.380 reasons why I think it’s such an
01:27:53.760 important tool
01:27:55.560 third thing is it democratizes data
01:27:59.580 which you do too I mean incredible how
01:28:01.860 you do that with your podcast but I
01:28:04.380 think one of the most hopeful and
01:28:06.840 exciting things that I’m seeing right
01:28:09.000 now
01:28:09.840 in the health space is that we’re going
01:28:13.440 from
01:28:14.760 this patriarchal relationship where
01:28:17.100 doctors hold the power and are The
01:28:19.620 Gatekeepers of data to patients and
01:28:23.280 clients having much more access to that
01:28:27.179 enchantment about their own chemistry
01:28:29.820 and their own biology so to me that is
01:28:32.580 so exciting like for me to be able to
01:28:34.800 I’ve got you know probably 100 patients
01:28:38.280 that are in a data stream with me where
01:28:41.460 we’re looking at their glucose and I can
01:28:43.199 I mean I’m on sabbatical so I’m not
01:28:45.000 doing this so much anymore but I can
01:28:46.380 call a patient be like why is your
01:28:48.480 glucose so high like what did you do oh
01:28:50.400 it was my birthday I had a piece of
01:28:51.840 birthday cake like that kind of
01:28:54.780 collaboration
01:28:57.659 that also is
01:28:59.699 teaching the patient to be their own
01:29:02.420 clinician to me that is a loop of
01:29:05.940 benevolence and integrity that I think
01:29:08.520 is essential to creating Health we’ve
01:29:11.940 got a disease care system we need the
01:29:14.340 democratization of data to become a
01:29:17.280 health-based system
01:29:19.320 Amen to that a million times over we
01:29:22.320 share that sentiment I can tell it at a
01:29:25.199 deep level I I think the pandemic
01:29:27.480 actually assisted in well harm to many
01:29:30.060 things but it assisted in people’s
01:29:31.620 understanding that um no magic fairy nor
01:29:35.340 the government nor any anyone was going
01:29:37.500 to arrive at their door with a kit of
01:29:39.600 things to make them healthy right that
01:29:41.340 provide sunlight movement sleep and all
01:29:43.199 the various aspects of nutrition no
01:29:45.420 nothing nothing that everyone has to
01:29:48.300 have access to first and foremost and
01:29:50.940 then
01:29:51.600 Implement those things as best they can
01:29:53.520 speaking of which and kind of circling
01:29:56.040 back to this idea of people in their
01:29:57.239 late teens 20s 30s and onward
01:29:59.520 if you had a magic wand
01:30:01.440 and you could give like two or three
01:30:03.960 don’ts or to make it personal if you
01:30:06.780 could go back in time and
01:30:08.760 erase certain behaviors what would the
01:30:11.880 the don’ts category be
01:30:15.179 um you can tell us more than two or
01:30:16.980 three
01:30:17.880 um but if the goal is to maximize
01:30:19.940 vitality and Longevity and those are not
01:30:23.940 always uh parallel to one another right
01:30:27.120 they’re certainly not the same thing
01:30:28.199 sometimes orthogonal but let’s just say
01:30:30.659 fertility
01:30:32.280 being a proxy for vitality and Longevity
01:30:34.800 I think people will sometimes forget
01:30:35.699 this that fertility isn’t just about
01:30:36.840 people who want to conceive children
01:30:37.920 it’s also it’s a it can serve as a proxy
01:30:40.620 for vitality and Longevity so what would
01:30:43.500 you like to see patients let’s focus
01:30:45.900 first on female patients but
01:30:48.239 um if it extends to male patients as
01:30:49.860 well what would you like to see them not
01:30:51.600 do yeah or do far less of I really like
01:30:54.840 that
01:30:56.280 so I would say a few things I’ll just
01:30:57.960 headline them and then we can go into
01:30:59.219 detail number one sleep
01:31:01.500 I do want to diverge from you a little
01:31:03.480 bit on some things but sleep is probably
01:31:05.460 not one of them oh well feel free I mean
01:31:07.739 you’re the one that worked 100.
01:31:09.739 120 hours a week sleeping much then I
01:31:12.780 can’t imagine unless unless you lived in
01:31:14.100 a different reality than I do
01:31:15.960 um uh you know and there are times in my
01:31:18.239 career where I was pulling all-nighters
01:31:19.679 and sleep deprived there’s just it I
01:31:21.659 don’t recommend it but I did it yeah I
01:31:24.000 hope you don’t do that anymore no longer
01:31:25.620 if I can avoid it but there were years
01:31:27.420 many years where it was like all right
01:31:29.639 here we go and I’m quite
01:31:31.679 um
01:31:32.520 Adept at it for one cycle yeah but two
01:31:35.699 nights I kind of start to fall fall
01:31:37.139 apart totally yeah so I would say sleep
01:31:39.780 alcohol High perceived stress and I’d
01:31:43.260 love to talk about maybe
01:31:45.000 um the date on telomeres and what we
01:31:47.040 know so you’d like to see people get
01:31:48.600 enough sleep so don’t don’t just yeah
01:31:51.600 not all of these are concordant so um
01:31:54.120 not enough sleep too much alcohol too
01:31:57.239 much perceived stress
01:32:00.120 eating the wrong Foods
01:32:03.600 toxic relationships
01:32:07.500 and isolation and then number six
01:32:12.719 um
01:32:14.340 not moving enough or not moving and
01:32:17.159 exercising in a way that really fits
01:32:19.080 with your body so we start with that one
01:32:21.840 actually just because it’s such a and
01:32:23.280 then work backwards um uh that’s
01:32:25.739 interesting I I
01:32:27.480 think nowadays people appreciate the
01:32:29.400 need for quote unquote cardio I know
01:32:31.620 that the the exercise physiologists
01:32:33.480 cringe and and dissolve into a puddle of
01:32:35.699 Tears when I say that but getting the
01:32:37.380 heart rate up over some period of time
01:32:39.780 longer than 10 minutes
01:32:41.820 in order to generate cardiovascular
01:32:44.159 health circulation so and resistance
01:32:46.260 training of some kind maybe flexibility
01:32:47.820 what do you mean by Body phenotype or
01:32:50.280 and exercise I’ll speak from personal
01:32:52.980 experience so what I did through I mean
01:32:56.280 I gave up my 20s to Medicine
01:32:58.860 and during that time I occasionally got
01:33:01.920 to the gym you know at UCSF on Parnassus
01:33:04.679 you could go to the gym and then as soon
01:33:06.900 as your beeper went off you’re back into
01:33:09.000 the hospital
01:33:10.560 but I didn’t exercise much I had um do
01:33:12.960 you remember Nordic tracks I had a
01:33:14.400 Nordic Track in my house and that was
01:33:16.320 that was like it what I believe because
01:33:19.500 for me the primary
01:33:22.560 outcome that I’m interested in is
01:33:24.540 cardiometabolic health
01:33:26.340 so when it comes to exercise what I
01:33:28.260 really feel
01:33:29.280 if we’re going to be at a population
01:33:30.840 level
01:33:32.820 I feel that about a third cardio
01:33:35.580 two-thirds resistance training is based
01:33:39.480 on my synthesis of the literature the
01:33:41.820 best combination
01:33:43.260 and I think there’s you know as you
01:33:45.239 described with your sign
01:33:47.940 um study I think there’s a minimal
01:33:50.340 effective dose which for a population is
01:33:53.880 about 150 minutes I think most of us
01:33:56.460 need a lot more than that per week per
01:33:59.460 week but I think you know for me
01:34:02.699 because I have a phenotype that
01:34:06.480 produces a lot of insulin kind of
01:34:08.580 depending on
01:34:09.780 how I’m on my game I have a lot of
01:34:12.540 glucose so I have to exercise a lot more
01:34:14.880 to dispose that glucose so I think you
01:34:18.120 then have to move from medicine for the
01:34:20.699 population or prescriptions for the
01:34:22.980 population to what works for the
01:34:25.380 individual
01:34:26.940 I think that recommendation is fantastic
01:34:29.880 um I think resistance training well let
01:34:32.159 me put it this way I’m neither a trainer
01:34:33.960 nor a physician but I’ve seen in family
01:34:35.580 members that were doing
01:34:38.040 I wouldn’t say a lot of cardio but just
01:34:39.780 cardio that when they add resistance
01:34:41.580 training everything in terms including
01:34:43.800 their biomarkers
01:34:46.260 um have improved dramatically yes in
01:34:48.780 particular for female members of my
01:34:50.760 family well one of the one of the
01:34:52.860 mediators that I think is important
01:34:54.420 especially for people who do what I call
01:34:56.219 chronic cardio which is what I did
01:34:59.219 is cortisol
01:35:00.900 so we know that
01:35:02.659 Runners especially marathon runners
01:35:05.159 people who do a lot of cardio and don’t
01:35:08.699 do much resistance training they tend to
01:35:10.440 have much High cortisol levels and you
01:35:12.300 can buffer that with vitamin C vitamin C
01:35:14.159 can decrease the effect but
01:35:17.280 chronic cardio doesn’t always serve
01:35:19.679 people so quick personal example when I
01:35:22.500 first started measuring hormone panels
01:35:24.420 in myself I went to my physician and I
01:35:27.900 said I’m 35. I’ve had one kid I want to
01:35:31.500 have another kid
01:35:32.699 I’ve never been so exhausted in my life
01:35:35.639 I just feel like I’m pushing a rock up
01:35:37.199 the hill
01:35:38.159 I’ve got this belly fat that I don’t
01:35:39.780 like and
01:35:41.760 um
01:35:42.360 I don’t want to have sex with my husband
01:35:44.340 so
01:35:45.719 what do you think what can we do about
01:35:47.280 this
01:35:48.179 and he offered
01:35:49.860 a birth control pill
01:35:51.480 and an antidepressant oh goodness so I
01:35:54.239 left him and I went to the lab and I ran
01:35:56.760 a hormone panel and my cortisol was
01:35:59.100 three times what it should have been my
01:36:01.260 insulin was in the 20s I was fasting my
01:36:04.260 glucose was 105.
01:36:06.480 my thyroid was mildly abnormal my
01:36:10.500 progesterone was low and that set me on
01:36:13.380 this course of realizing that
01:36:16.500 what I was doing as a physician taking
01:36:18.600 care especially of women was not getting
01:36:21.900 to some of these root causes that are so
01:36:24.000 essential and I would say I had to start
01:36:26.159 first with cortisol
01:36:28.139 at that time I was running four miles
01:36:30.360 three times a week four times a week
01:36:32.040 that was just racing my cortisol further
01:36:34.980 so that was not the right exercise for
01:36:36.780 me I needed more adaptive exercise I
01:36:38.820 started doing Pilates more yoga that
01:36:41.460 helped to lower my cortisol I mean it
01:36:43.260 started me on you know changing the way
01:36:45.840 I was managing perceived stress and it
01:36:48.000 also changed my supplement Richmond
01:36:50.219 can we talk about that and what the
01:36:51.900 moment you said lowering cortisol
01:36:53.520 thought of the two supplements that come
01:36:56.100 to mind are
01:36:57.780 um ashwagandha which I think can
01:36:59.460 potently reduce cortisol but I’ve heard
01:37:01.800 some recommendations about cycling it
01:37:04.620 and I’ve always wondered about time of
01:37:06.420 day for ashwagandha intake because sort
01:37:08.520 of quote unquote want cortisol elevated
01:37:10.679 in the early part of the day yes and we
01:37:12.420 know this
01:37:13.500 uh we know you do not want cortisol
01:37:16.020 peaking later in the day no you do not
01:37:17.880 interferes with sleep interferes with
01:37:20.159 sleep
01:37:21.179 um and then the other supplement is uh
01:37:23.760 rhodiola rosacea do I am I pronouncing
01:37:25.920 that correctly yeah so radiola is very
01:37:27.780 effective it’s been shown in multiple
01:37:29.580 randomized trials to lower cortisol so
01:37:31.620 that could be very effective what sort
01:37:33.360 of doses I’ve started taking it recently
01:37:35.280 by the way and I made a huge mistake I
01:37:37.139 like to make the mistakes first so then
01:37:38.639 my audiences don’t make them
01:37:41.100 um as I was taking it I heard it was an
01:37:42.840 adaptogen so I thought oh I’ll take it
01:37:44.340 before resistance training but of course
01:37:46.380 you want the cortisol Peak during
01:37:47.760 resistance training because that’s going
01:37:49.380 to set in motion the Adaptive response
01:37:50.820 so I start taking it later in the day
01:37:52.080 and it’s really improved I would say my
01:37:54.239 late day second half of the day
01:37:56.280 cognition this is subjective to be fair
01:37:58.860 I just feel like I’m in a more even
01:38:00.960 plane of attention in the second half of
01:38:02.880 the day so you’re describing an NF1
01:38:04.920 experiment right which is organic data
01:38:06.780 well it is not anecdotal so I was taught
01:38:11.040 at Harvard Medical School that the
01:38:13.320 hierarchy of evidence starts at the
01:38:15.480 lowest with expert opinion you know case
01:38:19.139 studies then you’ve got cohort studies
01:38:21.960 and you’ve got
01:38:23.300 observational data that’s prospective
01:38:25.560 then you have randomized trial but the
01:38:27.480 highest quality evidence of all is the
01:38:29.699 end of one experiment where you serve as
01:38:32.040 your own control
01:38:33.300 so what you’re describing with rhodiola
01:38:34.920 I would frame that as an end of one
01:38:36.480 experiment where you have a washout
01:38:38.280 period and you compare before and after
01:38:40.199 and I’d like to measure some other
01:38:41.880 metrics to see if there’s an effect
01:38:43.739 including your cortisol so radial has
01:38:46.380 been shown in multiple randomized trials
01:38:48.000 to reduce cortisol
01:38:50.280 the other thing that I think is super
01:38:51.840 effective is phosphatidylserine PS for
01:38:55.620 short
01:38:56.880 fish oil also more modestly reduces
01:38:59.880 cortisol
01:39:02.000 ashwagandha is interesting so in my
01:39:05.520 first book the hormone cure
01:39:07.679 which I read by the way you did I did I
01:39:10.139 was hoping that was the one you read I
01:39:11.340 did I read it and it’s spectacular and I
01:39:13.380 thought going into it I had this like
01:39:15.179 you know let’s just call it what it was
01:39:17.040 it’s called male bias like is there
01:39:18.300 going to be anything in here for me
01:39:19.380 because uh I’m I don’t have ovaries and
01:39:21.780 you know it’s gonna be and it was
01:39:23.219 immensely informative
01:39:25.440 um so thank you yeah I have very fun
01:39:27.600 Recollections of the the walks I took
01:39:29.280 listening to it and then I own the print
01:39:30.719 version too so I like to switch back and
01:39:32.520 forth so thank you for that it’s a it’s
01:39:34.560 a superb book for anyone to read yeah
01:39:36.600 yeah I so appreciate that
01:39:38.760 so
01:39:40.320 in chapter four you may or may not
01:39:42.420 remember that ashwagandha at least the
01:39:45.179 time that I wrote that book
01:39:46.460 ashwagandha’s data is not great but lack
01:39:49.380 of proof is not proof against so with
01:39:51.560 ashwagandha most of the data comes from
01:39:54.179 thousands of years of using it in
01:39:56.040 ayurvedic medicine and it’s considered
01:39:58.460 again not my science hat it’s considered
01:40:01.500 a double adaptogen so that it’s
01:40:03.840 potentially helpful when you are a high
01:40:07.440 cortisol phenotype like I was like I
01:40:10.199 sometimes still am
01:40:11.760 or low cortisol
01:40:14.520 I haven’t found that in my patients
01:40:16.739 although I’ll give you one exception
01:40:18.840 so ashwagandha is mostly based on animal
01:40:21.179 studies there’s not as much human data
01:40:23.639 but it is used a ton in Integrative
01:40:25.980 Medicine
01:40:27.480 the
01:40:28.679 um there’s one supplement that I found
01:40:31.679 to be incredibly helpful for people who
01:40:33.840 tend to have high cortisol at night
01:40:35.880 and that’s called a cortisol manager
01:40:37.560 it’s by integrative Therapeutics
01:40:39.840 I don’t have a second
01:40:41.880 um supplement manufacturer that makes
01:40:44.040 something similar it’s their number one
01:40:45.719 selling supplement because it’s so
01:40:47.340 effective is it a cocktail of several
01:40:49.080 things it’s a combination of
01:40:50.239 phosphatidylserine and ashwagandha so
01:40:52.620 tell me more about phosphatidylserine I
01:40:54.480 am familiar with it for it’s been
01:40:57.120 mentioned by some guests that were on
01:40:59.340 the Tim Ferriss podcast long ago for
01:41:00.960 other reasons I think related to sleep
01:41:02.820 yes um and maybe that’s another reason
01:41:04.920 why you like it um but before we move on
01:41:07.980 from rhodiola is there a dosage of
01:41:09.659 rhodiola rosacea that you um so I would
01:41:12.239 refer people to my book because the
01:41:14.340 randomized trials and the doses that
01:41:16.500 were used are in there so I can’t
01:41:18.840 remember with rhodiola although I took
01:41:20.460 it this morning to prepare to be with
01:41:22.020 you yeah we can look it up and put a
01:41:23.880 show note caption so I can remember the
01:41:25.739 dose with phosphatidyl serum because I
01:41:27.420 take that regularly so 400 to 800
01:41:29.880 milligrams is the typical dose for PS
01:41:32.159 and what’s interesting is that in the
01:41:34.920 randomized trials that were done
01:41:36.900 400 milligrams was more effective than
01:41:39.119 800 milligrams interesting I’ve found
01:41:41.219 that for several supplements that the
01:41:42.719 lower dose was more effective yes
01:41:45.600 um yeah I won’t it doesn’t matter what
01:41:47.400 those were and so when you say PS you
01:41:49.440 were referring to by the way folks not
01:41:50.639 PCOS just because
01:41:52.460 scientists and clinicians are familiar
01:41:54.360 with and Military very familiar with
01:41:55.739 acronyms uh phosphatidylserion PSO 400
01:41:58.139 to 800 milligrams 400 being more
01:41:59.820 effective taken later in the day or
01:42:01.920 early day does it matter it depends on
01:42:04.020 when your cortisol is high so for me I
01:42:07.440 tend to you know what’s the pattern for
01:42:09.780 cortisol typically it rises to its peak
01:42:13.679 30 to 60 minutes after you get up then
01:42:16.560 it has this gradual kind of asymptotic
01:42:18.780 decline until you go to bed
01:42:21.060 so if you’re someone like me who Peaks
01:42:24.719 like way crazy high I don’t do that
01:42:26.940 anymore but that’s what I used to do I
01:42:28.920 needed phosphatidylserine in the morning
01:42:31.199 for people who are high at night who
01:42:33.900 have what’s known as a
01:42:35.940 a flat cortisol pattern or a inverted
01:42:39.060 pattern you want to take it at night
01:42:41.880 and the flat pattern just quick sidebar
01:42:44.340 is that that’s associated with a number
01:42:47.520 of conditions that most mainstream
01:42:49.800 Physicians don’t know about so a flat
01:42:52.020 pattern where it’s low in the morning
01:42:53.760 and it’s high at night is associated
01:42:55.860 with anxiety depression
01:42:58.020 uh decreased survival from breast cancer
01:43:00.239 that was studied at Stanford by David
01:43:02.280 Spiegel that’s that he was my
01:43:05.159 um collab close even collaborator even
01:43:07.920 uh on the breath work study that we oh
01:43:10.560 interesting yeah he’s our associate
01:43:12.360 chair of Psychiatry now so a wonderful
01:43:14.460 human being has amazed has been a guest
01:43:16.320 on this podcast and and I’m now
01:43:18.119 fantasizing about a conversation that
01:43:19.679 includes uh a panel of of uh Incredible
01:43:23.520 Minds like you and David from the
01:43:24.960 clinical side so in any case um yeah the
01:43:27.300 late shifted cortisol not good not good
01:43:30.080 and it seems to have the worst
01:43:35.480 immune Downstream
01:43:38.159 issues of any of the cortisol patterns
01:43:41.280 so that’s really important to know about
01:43:43.080 because it then maps to things like
01:43:46.440 um
01:43:47.100 it’s related to PTSD
01:43:49.440 so that’s the pattern we see like in
01:43:51.060 vets who’ve got PTSD as well as others
01:43:53.580 it maps to autoimmunity it maps to
01:43:57.600 fibromyalgia
01:43:59.460 I was told that 1 in 12 people
01:44:04.020 um have are heterozygous so one mutant
01:44:07.980 copy or a hypomorphic for some some
01:44:10.739 mutation in adrenal related genes so
01:44:14.219 congenital adrenal hyperplasia is that
01:44:16.679 true and if so that means that 1 in 12
01:44:19.320 people walking around are cranking out
01:44:21.179 far too much cortisol or not enough
01:44:22.800 cortisol or the cortisol system is
01:44:25.199 already skewed in a direction that makes
01:44:26.639 life more challenging at the levels
01:44:28.380 we’re talking about
01:44:30.239 um did I hear that correctly because
01:44:31.800 that 1 in 12 is not a small number it’s
01:44:33.960 not a small number it fits with what I
01:44:36.000 see clinically
01:44:37.440 I mean I want to see that data just to
01:44:39.960 see
01:44:40.800 um what does that mean and could you
01:44:43.199 modulate it with environmental
01:44:44.760 influences but it certainly fits with
01:44:47.699 what I see you know I was taught once
01:44:49.800 again in mainstream medicine that in
01:44:52.020 terms of adrenal function
01:44:55.260 it’s very binary how most clinicians
01:44:58.920 think about it you either have Addison’s
01:45:02.040 disease and you don’t make enough
01:45:03.000 cortisol or you’ve got cushions or
01:45:05.580 Cushing weed pattern and you make too
01:45:07.500 much cortisol and anything in the middle
01:45:09.300 is normal and my experience is that hell
01:45:12.780 no like there are those of us like me
01:45:15.060 who make a lot of cortisol I don’t have
01:45:16.739 cushions maybe I’ve got one of these I
01:45:19.800 wouldn’t call it a mutant Gene I would
01:45:21.540 call it more of a
01:45:23.420 vulnerable Gene so maybe I have one of
01:45:26.580 those maybe that’s part of the reason
01:45:27.600 why I make you know two to three times
01:45:29.820 what I should be I’m aware of certain
01:45:32.520 groups of individuals from within the
01:45:35.340 military sector that
01:45:37.380 um have there’s a more frequent
01:45:39.480 occurrence of
01:45:42.060 some mutation in CCH congenital adrenal
01:45:45.420 hyper prevention not necessarily two
01:45:46.560 copies which will if people look that up
01:45:48.119 they’re going to go oh wow there’s all
01:45:49.380 these phenotypes and
01:45:52.139 um but sort of hypomorphic type thing so
01:45:55.500 you know less than or too much cortisol
01:45:57.960 and they are very good at staying up
01:46:00.060 multiple days per night right multiple
01:46:02.940 nights in the series so they can pull
01:46:04.679 all-nighters very easily yeah they can
01:46:06.480 push harder when most people would quit
01:46:08.040 and everyone thinks well that’s a great
01:46:09.480 phenotype to have but guess what it’s
01:46:11.219 because they hyper produce cortisol yeah
01:46:12.960 and um so that’s interesting and I think
01:46:17.159 if we were to panel medical students and
01:46:20.219 graduate students and you would look at
01:46:21.659 you know who’s pulling excessively long
01:46:23.340 hours who’s stressed out a lot even
01:46:26.219 outside of Academia and medicine and
01:46:28.500 pushing pushing pushing really hard I
01:46:30.119 think the ability to push and not crash
01:46:32.280 we think of it as adaptive but in some
01:46:34.679 sense it’s maladaptive over a series of
01:46:36.420 years which is sort of what you
01:46:37.980 described earlier yeah it’s such a good
01:46:39.840 point because
01:46:42.000 you know you in some ways you want to
01:46:43.980 select for that in certain professions
01:46:46.440 like in the military like in medicine
01:46:50.040 um
01:46:51.719 but I would wonder for those folks about
01:46:54.600 the downstream consequences of producing
01:46:57.060 so much cortisol oh it’s got to be
01:46:58.860 detrimental for their health it’s got to
01:47:00.480 be in the long run and and you see that
01:47:02.040 but even the data shows that if you’re
01:47:04.560 someone like me who makes a lot of
01:47:06.000 cortisol
01:47:07.139 higher rates of depression like 50 of
01:47:09.360 people with major depression have high
01:47:11.340 cortisol levels higher rates of suicide
01:47:14.940 um much more metabolic dysfunction we
01:47:17.820 know that trauma as an example maps to
01:47:20.460 an increased risk of glucose metabolism
01:47:23.400 issues and certainly High cortisol does
01:47:26.100 that because it’s one of the jobs of
01:47:27.960 cortisol is to manage a glucose
01:47:30.179 and it’s
01:47:32.460 it kind of sets you up for
01:47:34.860 um this one
01:47:36.480 number five which is toxic relationships
01:47:39.239 you know someone who hyper produces
01:47:41.280 cortisol it’s hard to live with someone
01:47:43.500 like that it’s also I would say people
01:47:45.600 that have this
01:47:47.159 um let’s just call it biological
01:47:49.260 resilience
01:47:50.400 it’s not always adaptive because you can
01:47:52.560 stay in bad circumstances longer the
01:47:54.600 ability to to crash
01:47:56.820 provided it’s not suicide or life life
01:47:59.219 destroying or you know long Arc of
01:48:02.520 of pause and the requirement to you know
01:48:04.860 take two years off from work or school
01:48:06.420 or something
01:48:07.920 um the ability to keep pressing on is a
01:48:10.020 double-edged sword let’s put it that way
01:48:12.300 um I want to make sure in staying within
01:48:15.060 this conversation uh because you
01:48:16.739 mentioned Foster dial serine we talked
01:48:18.360 about rhodiola rosacea we talked a bit
01:48:21.360 about ashwagandha you’ve also talked
01:48:23.040 about Omega-3s and fish oil in
01:48:24.719 particular I’d love to know your
01:48:26.159 favorite sources of these I think
01:48:27.480 nowadays there’s more General acceptance
01:48:30.659 that getting these essential fatty acids
01:48:33.239 is important do you have a threshold
01:48:35.520 level of sort of grams I I’ve encouraged
01:48:38.040 uh
01:48:39.360 um podcast listeners to consider
01:48:41.639 depending on what they’re eating to try
01:48:43.260 and get a gram of EPA or more per day
01:48:46.260 does that seem excessive and what are
01:48:48.719 the real data on epa’s because then the
01:48:51.560 cardiovascular experts always hit back
01:48:54.239 and say oh no you know it’s not good for
01:48:55.920 cardiovascular health and then you go oh
01:48:57.540 it’s better than antidepressants and
01:48:59.340 other studies and they go no so I feel
01:49:01.260 like if you really want to make your
01:49:02.940 life difficult if you want to raise your
01:49:04.080 cortisol you go on Twitter and you say
01:49:06.179 something positive about Omega-3s and
01:49:07.739 fish oil and
01:49:10.080 um and you learn a lot
01:49:11.880 um what are your thoughts on Omega-3s I
01:49:13.980 take a lot of them I’ve always been a
01:49:15.300 big fan yeah so this is where I
01:49:17.159 personalize I think some people need
01:49:19.739 more than others and what I do is I
01:49:23.580 measure your level so this gets back to
01:49:25.679 nutritional testing so for you I would
01:49:28.139 suggest an Omega Quant or one of my
01:49:31.260 favorite cardiometabolic panels is to do
01:49:33.600 a Cleveland heart lab so I think they
01:49:36.060 they give me the most reliable
01:49:37.440 information not just for lipids and
01:49:40.080 subclasses and you know NMR
01:49:42.179 fractionation but it also gives me an
01:49:44.760 insulin resistance score it gives me
01:49:48.119 um levels of Omega-3s great we’ll
01:49:50.760 provide links to these different sites
01:49:52.679 so that people but one quick thing about
01:49:54.600 that the whole story is not Omega-3s and
01:49:58.440 taking fish oil so the work of Charlie
01:50:00.900 Sirhan at the Brigham is showing that
01:50:05.040 the way that we resolve inflammation
01:50:10.560 our understanding of it is really I
01:50:13.199 think in the learning to crawl stage and
01:50:15.719 so if you look at the omega-3 6 pathway
01:50:19.199 in the body
01:50:20.880 fish oils can help you know kind of push
01:50:24.020 the reactions in a particular direction
01:50:26.600 but typically they’re not enough for the
01:50:29.639 resolution of inflammation now what most
01:50:31.980 people do including my MBA players is
01:50:34.800 they pop an ibuprofen or something like
01:50:38.040 that when they’ve got inflammation
01:50:39.659 that’s got lots of other side effects
01:50:41.880 that are not so good for you and we know
01:50:44.699 in terms of the resolution of
01:50:46.440 inflammation that taking something like
01:50:49.679 ibuprofen reduces the amplitude of
01:50:52.020 inflammation by about 50 percent but
01:50:54.239 then it potentially blocks the complete
01:50:57.360 resolution of inflammation
01:50:59.219 so there’s these new supplements that
01:51:01.500 you may have heard of called specialized
01:51:03.179 pro-resolving mediators there’s a lot of
01:51:05.219 different supplement companies that make
01:51:06.659 them and that combined with fish oil
01:51:09.679 seems to be the best combination and
01:51:12.060 what I do for athletes who’ve got you
01:51:14.280 know kind of the normal aches and pains
01:51:16.100 of the training load they have is all
01:51:19.560 combine a little aspirin
01:51:21.719 small dose just like 81 milligrams or
01:51:24.719 two of those baby aspirin together with
01:51:27.239 fish oil plus specialized pro-resolving
01:51:30.360 mediators and there’s some that are NSF
01:51:32.040 they’re certified for sports but the
01:51:35.159 the dose I would say with my patients
01:51:38.219 some of them only need
01:51:40.199 a thousand milligrams your Gram that you
01:51:42.659 mentioned for the population some of
01:51:44.580 them need
01:51:45.600 six grams together with spms
01:51:48.540 so I think it has to be personalized
01:51:51.540 how young
01:51:52.800 um
01:51:53.940 is it okay for
01:51:56.159 people to start taking Omega-3s for
01:51:59.340 instance young women and their teens
01:52:02.340 people in their 20s and their 30s young
01:52:04.260 guys in their 20s and 30s should they
01:52:06.840 take fish oil if just as a assuming
01:52:09.300 they’re not going to get anything tested
01:52:10.380 I’m thinking about the college student
01:52:11.580 who is really into biomarkers and that
01:52:13.920 sort of thing we’ll go do some of this
01:52:16.020 um
01:52:16.820 but many people won’t but they want to
01:52:19.020 do the right thing so they’ll try and
01:52:20.159 drink a little less hopefully hopefully
01:52:21.360 they won’t smoke or vape please don’t
01:52:22.980 smoke or vape the idea that vaping is
01:52:25.139 okay it’s like we had it was so bad so
01:52:28.199 bad for everything we’re talking about
01:52:29.219 let’s end that it’s like exactly so just
01:52:31.560 you know avoid hopefully they’ll try and
01:52:33.780 avoid those things hopefully they’ll
01:52:35.460 avoid hard drugs
01:52:37.260 um hopefully they’ll avoid getting any
01:52:38.820 STIs if they do they’ll resolve them
01:52:41.040 quickly hopefully yes um so but they
01:52:44.340 might say oh well okay I’m willing to
01:52:46.020 you know take some magnesium or take
01:52:47.760 some phosphodel serine buffer my
01:52:49.199 cortisol eat some vegetables
01:52:51.179 um should they consider taking fish oil
01:52:53.040 as a kind of across-the-board
01:52:54.480 inoculatory thing so I put to rank order
01:52:56.880 these I would say fish oil yes
01:52:59.940 I think a thousand milligrams as a
01:53:01.739 general recommendation is good but I
01:53:03.360 also have a food first philosophy so my
01:53:06.000 preference would be that they’re having
01:53:07.260 salmon or some kind of Smash fish and
01:53:10.199 they’re getting that as the primary
01:53:12.239 source of their Omega-3s and then the
01:53:14.400 days that they don’t have fish I
01:53:16.199 recommend it probably twice a week that
01:53:18.060 they take fish oil then I would put
01:53:19.860 magnesium next since so many people are
01:53:22.080 deficient then I’d probably put vitamin
01:53:24.000 D
01:53:24.960 what how many IU of vitamin D per day
01:53:27.060 well you keep asking me this like for
01:53:28.980 the the population yeah well for the let
01:53:31.080 me put it this way for the laze for the
01:53:33.060 lazy person
01:53:34.500 or and this is an or not an and or the
01:53:38.219 person who
01:53:40.320 um just doesn’t have the finances to go
01:53:42.480 get measured yeah levels measured
01:53:44.219 because you know our audience is a huge
01:53:45.840 range we’ve got people who can have tons
01:53:47.340 of disposable income that list in the
01:53:48.719 spot we have people have no disposable
01:53:50.219 income so a thousand to two thousand
01:53:52.020 international units but my you know what
01:53:54.300 I do is I dose to a serum level that’s
01:53:57.600 between about 50 and 90. great and so I
01:54:00.960 have a vitamin D receptor
01:54:02.820 uh snip and so I need to take about 5
01:54:05.940 000 a day to get to what I need a lot of
01:54:08.159 people don’t need that
01:54:09.840 and you know there’s some supplements
01:54:12.540 that
01:54:14.159 I don’t know if they need so you
01:54:15.540 mentioned phosphatidylserine for someone
01:54:17.639 who’s a college student and their
01:54:19.440 cortisol is completely normal they’re
01:54:21.119 wasting their money on PS they don’t
01:54:22.739 need it they might need it later but
01:54:24.480 they don’t need it now I’d like to make
01:54:26.040 sure that we Circle back to birth
01:54:28.020 control in particular oral contraceptive
01:54:31.199 birth control
01:54:33.300 and we should touch on iuds perhaps
01:54:36.420 a little bit more but what are your
01:54:39.119 thoughts on sort of pure estrogen birth
01:54:41.699 control this is what I learned when I
01:54:43.320 was in college is that birth control is
01:54:44.760 basically tonic estrogen so constantly
01:54:47.460 taking estrogen estrogen women are
01:54:48.960 taking estrogen so that they don’t get
01:54:51.600 the estrogen
01:54:53.580 priming of progesterone you’re not
01:54:55.739 getting any ovulation and I’ve known
01:54:58.560 women that have been taking oral Contra
01:55:01.679 or that took oral contraception as like
01:55:03.900 estrogen
01:55:05.340 pills basically for 5 10 15 years are
01:55:09.480 there long-term consequences of this as
01:55:11.340 it relates to pregnancy PCOS
01:55:14.219 menopause what if so what are some of
01:55:17.340 those consequences
01:55:19.199 um
01:55:19.800 what are your concerns what do you like
01:55:21.480 about oral contraceptives what do you
01:55:23.219 dislike about them
01:55:24.780 I like how balanced you ask that
01:55:26.699 question so
01:55:28.260 women who take oral contraceptives as
01:55:31.020 long as you’re describing like 10 years
01:55:33.360 or longer we call those Olympic oral
01:55:36.000 contraceptive users
01:55:38.280 in terms of benefit I think that
01:55:40.440 especially when they first came out and
01:55:42.179 even now it gives women reproductive
01:55:44.340 choice and That’s essential
01:55:46.800 as you may know a reproductive Choice
01:55:48.840 has been declining recently so I’m a big
01:55:51.719 fan in that regard and we’ve got a lot
01:55:53.340 of data to show both the risks and also
01:55:57.000 the benefits of it
01:55:58.440 so I’ll speak first into the benefits
01:56:00.840 because
01:56:03.000 uh I’m gonna get on a soapbox a little
01:56:05.940 bit about the risks so we know that it
01:56:09.060 reduces the risk of ovarian cancer so
01:56:11.400 there’s something about this idea of
01:56:13.380 incessant ovulation that is not good for
01:56:16.679 the female body
01:56:17.940 so if you look at for instance women who
01:56:22.199 are nuns
01:56:24.060 who don’t take oral contraceptives and
01:56:27.119 they have a period every single month of
01:56:28.860 their reproductive lives they have a
01:56:30.960 greater risk of a brain cancer
01:56:32.940 so if you look then at women who have uh
01:56:37.500 several babies and they’ve got a period
01:56:39.480 of time when they’re pregnant that
01:56:41.280 they’re not ovulating and then they
01:56:42.659 breastfeed for some period of time they
01:56:44.580 have a lower risk of ovarian cancer so
01:56:46.980 oral contraceptives help with reducing
01:56:50.460 ovulation and reducing risk we know that
01:56:53.940 if you take the oral contraceptive for
01:56:56.880 about five years it reduces your risk of
01:56:58.500 ovarian cancer by 50 and that’s
01:57:00.840 significant because
01:57:02.880 were so poor at diagnosing ovarian
01:57:05.940 cancer early there’s really no method
01:57:08.580 that’s really effective we use ca125 and
01:57:12.000 ultrasound screen especially in women
01:57:13.860 who are at greater genetic risk but even
01:57:16.320 that often we diagnose it you know in a
01:57:18.659 later stage maybe just because that
01:57:21.119 statement is going to highlight for a
01:57:22.679 number of people the question of what
01:57:25.199 are some of the some earliest symptoms
01:57:27.659 that people can recognize without a
01:57:29.219 blood test so as ovarian cancer is it
01:57:31.500 going to be pain
01:57:32.699 so the problem is the symptoms are so
01:57:35.159 vague and they’re so non-specific one of
01:57:38.219 the most common symptoms is bloating
01:57:40.739 and we’ve already talked about
01:57:41.760 constipation we’ve talked about how
01:57:43.199 women have this longer track GI tract
01:57:46.500 and so bloating is a really common
01:57:48.000 experience for most women
01:57:49.980 you can have bulk symptoms you know
01:57:51.719 feeling like your your lower belly is
01:57:54.119 kind of pressed out
01:57:55.679 so
01:57:57.000 the way that we
01:57:59.219 inform women in terms of watching for
01:58:02.159 this is to get regular gynecologic exams
01:58:06.320 for women who are at high risk where
01:58:08.639 they have for instance an ultrasound for
01:58:10.440 some reason it shows a mass that we’re
01:58:12.300 concerned about there’s a way to triage
01:58:14.099 that in terms of what kind of evaluation
01:58:15.900 that they need and that’s the situation
01:58:18.060 where you might get a blood test called
01:58:19.800 the ca129
01:58:21.659 CA 125.
01:58:23.940 the um yeah the problem is the symptoms
01:58:27.000 are so vague it could be it depends on
01:58:29.880 how big the tumor is how much bulk you
01:58:32.159 have what it’s pressing on
01:58:34.679 so if
01:58:35.940 um taking estrogen and thereby reducing
01:58:39.119 the frequency of ovulation
01:58:40.820 lowers the risk of ovarian cancer should
01:58:44.280 women that are even women who are not
01:58:46.380 sexually active so they’re they’re not
01:58:48.119 actively trying to get pregnant or avoid
01:58:50.099 getting pregnant but if they’re not
01:58:51.599 sexually active then the probability of
01:58:53.699 conceiving unless they go through some
01:58:55.560 IUI or some other route is is very low
01:58:58.500 as far as I know
01:59:00.179 um so I was taught in high school anyway
01:59:02.699 um
01:59:03.540 would they be wise to suppress ovulation
01:59:06.239 for periodically using hormone-based
01:59:09.239 contraception just so that they can
01:59:10.560 offset the risk of ovarian cancer that’s
01:59:13.679 a very rational question and I would say
01:59:15.659 that’s what mainstream medicine has had
01:59:18.960 at its back to recommend oral
01:59:21.840 contraceptives not just for women who
01:59:23.699 are seeking contraception but
01:59:25.860 for acne for painful periods for really
01:59:30.060 kind of the drop of a hat they’re
01:59:32.340 prescribing oral contraceptives that’s
01:59:33.840 what I was taught to do
01:59:35.219 but there are so many consequences and I
01:59:37.619 think the issue here is more about
01:59:39.480 consent because
01:59:42.900 in OB GYN and I started out as a
01:59:46.080 board-certified ob gyn and I now mostly
01:59:48.780 see men but I was taught as an OB GYN to
01:59:52.800 convince women to go on the oral
01:59:54.420 contraceptive and I think a lot of that
01:59:55.920 is pharmaceutical influence
01:59:57.900 so maybe we could talk about the risks
02:00:00.780 and why the answer is no to your
02:00:03.420 question
02:00:04.260 um as we do that could I just ask is the
02:00:06.780 um the so-called ring the new it used to
02:00:09.300 be called The nuva Ring maybe that’s a
02:00:10.500 brand name but when I was in college
02:00:11.760 there was all this discussion about the
02:00:12.900 ring all right by both men and women for
02:00:15.119 reasons that don’t belong on the podcast
02:00:18.659 um use your imagination folks so
02:00:21.060 um is the the ring obviously it’s not
02:00:23.099 oral it’s not oral hormone contraception
02:00:25.440 but it’s hormone based right the rate is
02:00:27.480 releasing estrogen locally as opposed to
02:00:29.520 taking it orally but would you would you
02:00:30.960 slot it under what you’re about to tell
02:00:32.760 us in terms of the concerns
02:00:34.860 so we have less data about the ring
02:00:37.800 so the oral contraceptive is two
02:00:41.040 hormones it’s ethanyl estradiol
02:00:44.699 and it’s a progestin so it’s not the
02:00:48.960 normal
02:00:49.920 uh progesterone that your body makes
02:00:51.840 such ovaries make and your adrenals make
02:00:53.699 it is a synthetic form of
02:00:57.540 progesterone
02:00:59.099 and it is the same
02:01:01.400 progestin similar same class that was
02:01:05.520 shown to be dangerous and provocative in
02:01:07.320 the women’s health initiative so I’m not
02:01:09.599 a fan of progestins I do not recommend
02:01:13.080 them for any woman unless the
02:01:16.260 consequence of not taking them is
02:01:18.119 surgery or some other
02:01:20.699 um
02:01:22.320 you know unless it gives them some
02:01:24.239 freedom in some way so I don’t like
02:01:26.820 Protestants the uh nuva ring is estrogen
02:01:32.159 plus progestin but it’s released
02:01:34.500 transdermally through the vagina
02:01:36.900 so
02:01:38.159 given the the way that
02:01:40.739 um it’s delivered to the vagina
02:01:44.219 the doses are lower than what’s taken
02:01:46.380 orally
02:01:47.340 but in terms of some of the risks that
02:01:49.380 I’m about to talk about we don’t know
02:01:50.820 about much of the data we think that
02:01:53.400 it’s similar there’s probably a spectrum
02:01:55.260 of risk and maneuvering is a little more
02:01:58.440 towards the middle than you know what
02:02:00.719 I’m talking about with oral
02:02:01.679 contraceptives
02:02:03.060 are you ready for that yeah I’m ready
02:02:04.860 for the risks okay
02:02:06.480 so like with almost any pharmaceutical
02:02:09.900 the oral contraceptive depletes certain
02:02:12.480 micronutrients
02:02:14.219 so magnesium there’s certain vitamin B’s
02:02:17.040 that are depleted
02:02:18.300 uh
02:02:20.040 it also affects the microbiome that data
02:02:24.420 is not as strong but there seems to be
02:02:26.280 some effect and there’s also an
02:02:27.659 increased risk of inflammatory bowel
02:02:29.520 disease in autoimmune condition
02:02:31.679 it increases inflammatory tone
02:02:34.440 so the studies that I’ve seen increase
02:02:36.860 one of the markers of inflammatory tone
02:02:40.560 High sensitivity CRP by about two to
02:02:43.260 three x
02:02:44.820 it seems to make the hypothalamic
02:02:46.739 pituitary adrenal axis more rigid
02:02:51.239 so that you can’t kind of roll with the
02:02:53.520 punches and Wax and Wane in terms of
02:02:55.619 cortisol production the way that you can
02:02:57.420 off the birth control pill
02:03:00.420 it can affect thyroid function
02:03:03.900 I’m thinking of the slide that I have
02:03:05.699 that has like 10 problems associated
02:03:08.639 with oral contraceptive but that’s what
02:03:10.320 I can remember right now that’s very
02:03:12.179 helpful and it makes me wonder whether
02:03:14.159 or not if on the one hand oral
02:03:16.619 contraceptives are protective in women
02:03:18.659 it’s ovarian cancer but then they have
02:03:20.460 these other issues yeah there’s one
02:03:21.900 other I want to mention please
02:03:23.699 anytime you take oral estrogen it raises
02:03:27.000 sex hormone by Nick globulin and you’ve
02:03:29.099 talked to other podcast guests about
02:03:30.780 this Kyle I think sex hormone binding
02:03:33.540 globulin I think of as a sponge that
02:03:36.599 soaks up free estrogen and free
02:03:39.540 testosterone so when you go on the birth
02:03:41.699 control bill you raise your sex hormone
02:03:43.800 binding globulin it soaks up especially
02:03:46.199 free testosterone
02:03:48.060 and for some women it’s not a big deal
02:03:51.480 they don’t notice much of a difference
02:03:52.980 but then there’s a phenotype maybe
02:03:55.739 related to CAG repeats on the Androgen
02:03:58.440 receptor
02:03:59.699 who are exquisitely sensitive to that
02:04:02.400 decline in free testosterone so this
02:04:05.400 then opens the portal of talking a
02:04:07.380 little bit about testosterone in women
02:04:09.179 so we’ve mentioned already that it’s the
02:04:11.520 most abundant biologically the most
02:04:14.400 abundant hormone in the female system
02:04:16.199 even though men make almost 10 times as
02:04:18.960 much or even more than 10 times it is so
02:04:21.840 important for women it is essential to
02:04:24.360 so many things not just sex drive and
02:04:26.820 muscle mass and seeing a response to
02:04:28.560 resistance training but also confidence
02:04:31.440 in agency
02:04:32.940 and so those women who are so sensitive
02:04:35.940 to their testosterone level they’ve got
02:04:37.679 this high sex hormone binding globulin
02:04:39.719 their testosterone declines
02:04:41.940 what they describe is vaginal dryness
02:04:45.840 maybe a decline in sex drive but there’s
02:04:48.900 also this bigger issue related to
02:04:51.119 confidence in agency even risk-taking
02:04:53.159 from studies that we’ve done with MBA
02:04:55.380 students that I think is a serious
02:04:57.300 problem
02:04:58.739 maybe the most important out of all of
02:05:00.480 these things is that it can shrink the
02:05:02.580 clitoris by up to 20 percent
02:05:05.040 twenty percent and that includes the
02:05:07.800 regression of the of the nerves that
02:05:09.719 innervate the the clitoris is that I
02:05:11.940 mean that’s a very good question as a
02:05:13.800 neuroscientist yeah I would think uh I
02:05:15.719 used to teach uh the neural side of of
02:05:18.060 reproductive Health we need to do a
02:05:19.380 series on Sexual Health maybe you would
02:05:20.760 co-host that with me
02:05:22.280 we could certainly use your expertise I
02:05:25.260 think um yeah that’s a dramatic that’s
02:05:27.659 interesting number yeah but then let’s
02:05:30.179 go back to the sacred marketing if I’ve
02:05:31.860 got a woman that I think should not be
02:05:33.840 on the birth control pill maybe she’s
02:05:35.099 taking it for acne or she’s taking it
02:05:36.780 because her periods were a little
02:05:38.099 painful what I’m going to do is say
02:05:40.619 let’s leverage these other ways of
02:05:43.260 making your period less painful let’s
02:05:45.480 take the message of your painful periods
02:05:48.020 and figure out okay it’s your
02:05:50.699 inflammatory tone and we give you some
02:05:52.560 fish oil and spms maybe a little aspirin
02:05:54.719 when you’ve got your period like let’s
02:05:56.219 find some other ways to deal with it
02:05:57.719 then to take the oral contraceptive
02:06:00.000 which you have not received informed
02:06:01.980 consent about because it can trick your
02:06:05.099 by up to 20 now that usually
02:06:07.320 convinces most people to come reversible
02:06:10.980 the elevation in sex hormone binding
02:06:13.440 globulin does not seem to go away when
02:06:16.860 you come off the birth control pill
02:06:19.080 to me that is the biggest problem with
02:06:22.560 prescribing oral contraceptives now the
02:06:25.020 data that we have is limited there’s one
02:06:27.179 woman who uh Claudia has something
02:06:29.580 something who looked at sex hormone
02:06:32.099 binding globulin a year out from
02:06:34.380 stopping the birth control pill and it
02:06:36.360 was still elevated it wasn’t as high as
02:06:38.159 it was when they were on the pill but it
02:06:40.139 was still elevated so your question
02:06:42.119 about reversibility
02:06:43.679 I don’t know if we know the answer to
02:06:45.300 that
02:06:46.199 wow okay
02:06:48.239 um
02:06:49.020 that’s yeah that’s a significant
02:06:51.060 statement
02:06:52.080 and something that for consideration
02:06:55.080 related to this although this might seem
02:06:57.239 not related it is
02:06:59.820 how early do you recommend that women go
02:07:03.540 get their
02:07:05.159 follicle number assessed in other words
02:07:07.920 to get a size a sense of the size of the
02:07:09.960 ovarian reserve and their amh levels
02:07:12.480 measured um
02:07:14.340 I’m gonna I’m an amateur Outsider as I
02:07:16.860 say this but we have an episode on a
02:07:18.360 fertility where I just described the
02:07:20.340 ovulatory menstrual cycle yeah
02:07:23.099 um and I’m not the best person to answer
02:07:25.020 that yeah well I’m too far out from it
02:07:27.239 okay well um I suppose then from taking
02:07:29.699 the perspective of somebody who thinks
02:07:31.980 about fertility it in terms of at least
02:07:34.860 congruent with vitality and Longevity
02:07:37.639 given that it’s fairly non-invasive it’s
02:07:40.440 an ultrasound or a blood draw for amh or
02:07:42.719 both
02:07:43.739 is there any reason why a woman would
02:07:45.659 not want to get her follicle number
02:07:47.460 assessed or her amh levels assessed is
02:07:50.400 there any reason
02:07:51.719 why because I was shocked to learn that
02:07:53.880 most women don’t do this until they’re
02:07:55.980 hitting their late 30s or early 40s and
02:07:58.980 yeah they’re having conceived or they
02:08:00.659 suddenly decide that they want to
02:08:01.980 conceive and I thought why doesn’t every
02:08:04.800 doctor insist that their female patients
02:08:06.540 get have their amh level
02:08:09.060 addressed so that if they need to freeze
02:08:12.000 eggs cost it’s cost yeah so I think if
02:08:14.880 you’ve got the disposable income to do
02:08:16.619 it go for it it’s not included in a
02:08:18.900 standard blood panel no wow the only
02:08:21.420 women in my practice who’ve had amhs
02:08:24.300 done and have looked at their follicle
02:08:26.460 count are women who
02:08:28.320 want to freeze their eggs or and that
02:08:31.380 requires disposable income or they
02:08:35.520 um are having trouble getting pregnant
02:08:37.560 so they are in the reproductive
02:08:39.719 Endocrinology system and they’re getting
02:08:42.000 an evaluation and then they’re also
02:08:46.500 um the women who have symptoms of early
02:08:48.360 menopause so premature ovarian
02:08:51.060 insufficiency which is before age 40.
02:08:54.119 uh those are the women that I see
02:08:56.159 getting attested and I think you’re
02:08:57.719 right that it should be offered more
02:09:00.420 broadly it speaks to the democratization
02:09:02.580 of data again
02:09:04.020 and I think most women don’t know that
02:09:06.540 so you’re doing a huge service I think
02:09:08.219 to be speaking into this
02:09:12.540 one other point related to that is that
02:09:16.320 what I see in conventional medicine
02:09:19.860 is that when a woman asks for a hormone
02:09:22.199 panel
02:09:23.820 and she’s not trying to get pregnant she
02:09:26.340 usually gets told
02:09:27.840 that hormones vary too much
02:09:30.900 it’s a waste of money you don’t need it
02:09:34.320 or if you’re feeling hormonal why don’t
02:09:37.080 you go on a birth control pill
02:09:39.360 unless she’s trying to get pregnant
02:09:42.239 if she’s trying to get pregnant suddenly
02:09:44.400 those same tests are very reliable and
02:09:47.040 they get you know their their
02:09:49.080 testosterone their free testosterone
02:09:50.639 their thyroid panel they get their
02:09:52.320 estrogen and progesterone maybe they get
02:09:54.840 their cortisol they get their amh so
02:09:58.139 there’s a double standard
02:10:00.119 between those who want to get pregnant
02:10:01.739 and those who don’t and that needs to
02:10:03.540 end
02:10:04.679 I totally agree as I’ve learned more
02:10:06.179 about
02:10:07.020 um ovulatory cycle and amh and and the
02:10:10.560 antral population of follicles on it
02:10:12.659 it’s fascinating it just seems to me wow
02:10:14.880 a relatively straightforward test one
02:10:17.040 definitely invasive ultrasound but I
02:10:20.280 don’t consider that yeah that’s not I’m
02:10:22.139 not terribly invasive but invasive uh at
02:10:24.599 least but the other one just pure blood
02:10:26.040 test just seems like why wouldn’t I
02:10:28.320 wouldn’t this be offered or covered by
02:10:29.580 insurance or or you know that anyone
02:10:31.260 that wanted but now now I understand why
02:10:33.619 you mentioned menopause
02:10:36.360 huge topic enormous topic we had a guest
02:10:40.619 on the podcast who’s not a clinician who
02:10:44.159 said something in passing so I wanna I’m
02:10:46.920 likely to get this wrong
02:10:49.139 um but what they said was that the
02:10:50.820 results of the large-scale trials on
02:10:53.040 hormone replacement therapy for women
02:10:55.260 for menopause said something to the
02:10:57.599 effect of if the hormone therapy was
02:10:59.460 started early enough it was very
02:11:01.440 beneficial for yes vitality and health
02:11:03.840 outcomes whereas if women
02:11:05.699 went through menopause and then
02:11:07.440 initiated the hormone therapy
02:11:09.659 hormone replacement therapy that it
02:11:12.719 could be detrimental to their health
02:11:14.820 so first of all do I recall that
02:11:17.639 statement correctly and then second of
02:11:19.500 all what sorts of hormones are being
02:11:21.780 replaced is it just estrogen and how is
02:11:24.300 that done is it done through birth
02:11:25.619 control so oral contraceptives nuvarings
02:11:28.440 what are your thoughts on menopause when
02:11:30.900 should people start thinking about it
02:11:32.340 and what is the
02:11:34.679 palette of things available so that we
02:11:36.840 can do an entire episode with you on on
02:11:39.300 this topic in the future but just to I
02:11:41.280 you know I get a lot of questions about
02:11:42.540 this and and I’m guessing based on
02:11:44.820 everything you’ve told me today that
02:11:46.260 there are women in their 30s that while
02:11:48.960 they may be 20 years out from menopause
02:11:51.060 probably should be doing things now in
02:11:53.159 anticipation of that yes so we haven’t
02:11:55.260 talked about the 30 something but I
02:11:56.760 totally agree with you the more you know
02:11:59.159 about your phenotype your hormonal
02:12:01.320 phenotype when you’re in your 30s you’re
02:12:03.960 set up in terms of what to do in the
02:12:06.540 future especially things like your
02:12:08.880 thyroid your estrogen and progesterone
02:12:10.500 levels because you can replace
02:12:13.340 to a state of Youth thyroid
02:12:16.440 whatever that is for you
02:12:18.480 you can replace I don’t usually go
02:12:20.699 exactly back to where the estrogen and
02:12:22.679 progesterone levels were but we can get
02:12:24.780 pretty close so in your 30s having a
02:12:27.480 base case I think is really essential
02:12:29.639 so you spoke to the Women’s Health
02:12:31.619 Initiative which was published in 2002
02:12:34.560 and we went from a huge number of women
02:12:37.260 taking hormone therapy to a very small
02:12:40.139 percentage like in the range of five
02:12:41.760 percent
02:12:42.659 and that means we’ve got millions
02:12:44.760 millions of women who are suffering
02:12:47.400 needlessly with things like insomnia
02:12:50.579 difficulty with their mood difficulty
02:12:53.280 with sex drive feeling like they are
02:12:56.699 closing the store in terms of sex
02:12:59.520 because they’re not on hormone therapy
02:13:02.579 I would agree with the statement that
02:13:04.199 you made that hormone therapy particular
02:13:06.719 forms that are similar to what your body
02:13:08.699 always made when it’s given judiciously
02:13:11.340 at the right time
02:13:13.199 typically within five to ten years of
02:13:15.780 menopause which is 51 to 52 that it is
02:13:19.739 incredibly safe so
02:13:22.079 it’s a complicated study the women’s
02:13:24.119 health initiative but it was the the
02:13:26.520 wrong study in the wrong patients
02:13:29.159 with the wrong medications
02:13:31.739 and
02:13:33.239 um with some of the wrong outcomes so it
02:13:35.820 was powered to look at cardiovascular
02:13:37.800 outcomes it was not powered to look at
02:13:39.659 breast cancer it was stopped because of
02:13:42.300 breast cancer risk but what happened in
02:13:44.639 the control arm of the study was that
02:13:47.280 they had an incredibly low rate of
02:13:49.560 breast cancer
02:13:50.880 and so as a result they ended up having
02:13:54.659 this increased risk of breast cancer at
02:13:57.360 five years and they stopped the study
02:14:00.000 now the study was done with synthetics
02:14:02.040 it was done with conjugated equine
02:14:03.900 estrogen known as Premarin and medroxy
02:14:06.780 progesterone acetate those were the
02:14:08.699 so-called estrogen and progesterone
02:14:11.060 those are synthetic hormones we think
02:14:14.520 especially the progestin is associated
02:14:16.560 with the greater risk of breast cancer
02:14:18.199 although the the subsequent
02:14:21.739 re-evaluations of the data now 18 years
02:14:24.780 out have shown that
02:14:27.360 um
02:14:28.199 this problem with the control group and
02:14:30.719 no increased risk of breast cancer
02:14:33.780 um
02:14:34.440 and for the women who got estrogen only
02:14:36.719 those who had a hysterectomy the
02:14:38.820 Premarin they actually had a decreased
02:14:41.639 breast cancer risk and decreased breast
02:14:43.920 cancer mortality
02:14:47.159 so there’s a lot to be said about this
02:14:48.900 I’m trying to keep it really brief
02:14:51.900 but if you look at the women 50 to 60 So
02:14:56.280 within 10 years of menopause they’re the
02:14:58.679 ones who seem to have the greatest
02:14:59.760 benefit
02:15:00.960 so they had a decreased subclinical
02:15:04.159 atherosclerosis so less cardiovascular
02:15:06.420 disease they had an improvement in terms
02:15:09.360 of bone health
02:15:13.500 um less progression to diabetes and then
02:15:17.159 over the age of 60 they started to have
02:15:20.159 greater risk of certain outcomes such as
02:15:22.739 cardiovascular disease myocardial
02:15:24.300 infarction and so on
02:15:28.260 you asked about
02:15:30.420 um
02:15:31.500 what do I do
02:15:33.360 and
02:15:35.340 to me this problem is not just menopause
02:15:38.520 what’s more interesting is to talk about
02:15:40.920 perimenopause
02:15:42.480 so perimenopause is the the period of
02:15:45.360 time before your final menstrual cycle
02:15:48.119 and for most women depending on how it’s
02:15:50.460 tuned you are to the symptoms it can
02:15:52.980 last for 10 years so I’m still in Period
02:15:56.219 menopause it’s been like 20 years
02:15:58.440 because I’ve been tracking it so
02:16:00.000 carefully
02:16:01.560 it usually gets kicked off by having
02:16:03.480 your cycle get closer together so that
02:16:06.000 could happen in your 30s or your 40s you
02:16:08.219 go from 28 days to 25 days that sort of
02:16:11.040 thing you may notice that you start
02:16:12.719 sleeping more poorly because
02:16:13.860 progesterone is so important you talked
02:16:15.599 about that with Kyle
02:16:17.340 you may notice it as more anxiety
02:16:19.440 difficulty is sleeping and that probably
02:16:21.540 is related to the estrogen receptor so
02:16:24.900 your Alpha is estrogen receptor Alpha is
02:16:28.440 anxio
02:16:29.820 it increases anxiety
02:16:32.218 ER beta is associated with an anxiolytic
02:16:35.580 activity and then there’s a total of
02:16:38.280 about six estrogen receptors now there’s
02:16:40.740 the the g-protein-coupled estrogen
02:16:43.500 receptors and those are mixed anxiolytic
02:16:46.019 anxiogenic
02:16:47.638 so um there’s this whole period of
02:16:50.519 perimenopause and what’s Most
02:16:52.320 Fascinating to me and we’ve got to talk
02:16:54.179 about this either today or another time
02:16:56.420 is that there is this massive massive
02:16:59.760 change that happens in the female brain
02:17:02.519 that people are not talking about enough
02:17:05.099 and so looking at the work of Lisa
02:17:07.740 Moscone at Cornell
02:17:10.320 from uh starting around age 40. there is
02:17:14.218 this massive change in cerebral
02:17:16.200 metabolism so you can do fdg pet scans
02:17:18.959 you can look at glucose uptake and
02:17:21.540 there’s about
02:17:22.620 on average a 20 decline from
02:17:25.679 pre-menopause
02:17:27.240 you know up to like age 35
02:17:30.058 to perimenopause to post menopause
02:17:33.959 the women who are having the most
02:17:36.000 symptoms in perimenopause menopause The
02:17:38.099 Hot Flashes the night sweats the
02:17:39.540 difficulty of sleeping those are the
02:17:41.398 ones who have the most significant
02:17:43.040 cerebral hypomatabolism
02:17:46.500 so it’s almost like a
02:17:48.718 um I don’t I don’t want to scare people
02:17:50.160 with this language but it’s a
02:17:52.620 low level or let’s call it pseudo
02:17:55.500 dementia of sorts yes it it seems to be
02:17:58.439 a phenotype that you can then map
02:18:01.558 to Alzheimer’s disease because that’s
02:18:03.898 Lisa moscone’s work she’s looking at
02:18:05.939 okay
02:18:07.320 Alzheimer’s disease is not a disease of
02:18:09.359 old age it is disease of middle age what
02:18:11.760 are some of the biomarkers that we can
02:18:13.320 Define that can tell you what your risk
02:18:16.080 is I’ve got a mother and a grandmother
02:18:18.599 with Alzheimer’s disease you can believe
02:18:20.040 I am all over this data and insulin
02:18:22.620 resistance it’s a huge part of
02:18:24.478 sensitivity as we talked about before
02:18:26.700 um seems to be somewhere in there which
02:18:28.978 I think when that first when that idea
02:18:31.439 first surfaced a few people like really
02:18:33.058 but then of course right I mean the
02:18:34.439 brain is just incredibly metabolically
02:18:36.120 demanding organ
02:18:37.558 you deprive neurons of
02:18:39.540 fuel sources they or you make them less
02:18:41.939 sensitive to fuel sources they start
02:18:44.160 dying they certainly start firing less
02:18:45.898 it makes perfect sense and I think now
02:18:47.638 it’s thanks to Lisa’s work work that
02:18:49.859 you’ve you’ve done and talked about
02:18:51.420 quite a lot is um in your books and
02:18:54.000 elsewhere I think has really you know
02:18:55.679 highlighted for people that
02:18:58.080 metabolism and metabolomics is going to
02:19:01.439 be as important as genes and genomics
02:19:03.959 when it comes that’s right dementia
02:19:06.179 perhaps especially in women is it safe
02:19:08.879 to say that I think I think so because
02:19:14.040 we believe that this system is regulated
02:19:17.580 by estrogen
02:19:19.260 so the decline in estrogen starting
02:19:21.299 around age 40 43 is kind of the average
02:19:24.080 seems to be the driver behind cerebral
02:19:27.058 hypomatabolism the way I describe it to
02:19:28.920 my patients is
02:19:30.599 it’s like slow brain energy
02:19:33.000 so you walk into a room you can’t
02:19:34.620 remember why like you just notice that
02:19:36.660 you can’t manage all the tasks the way
02:19:38.700 that you once could like things are just
02:19:40.500 a little slower
02:19:41.820 and I say that to women and they’re like
02:19:44.160 I have that like help me
02:19:47.398 so this is then circling back to Whi
02:19:50.520 where women are scared to death of
02:19:53.100 taking hormone therapy and we’ve got all
02:19:56.100 of these women that are Marching toward
02:19:57.840 potentially a greater risk of
02:19:59.880 Alzheimer’s disease and they have this
02:20:02.280 opportunity in their 40s and their 50s
02:20:04.620 to take hormone therapy and they may not
02:20:06.720 be offered it
02:20:08.220 because the typical conventional
02:20:10.140 approach based on Whi is to say
02:20:13.200 unless you’re having hot flashes and
02:20:15.120 night sweats that are severe I’m not
02:20:16.979 going to give you hormone therapy and I
02:20:18.479 I just want to call that out I would say
02:20:20.160 no that is not the way to approach it
02:20:23.340 further
02:20:26.820 the concept right now in conventional
02:20:28.859 medicine is that hot flashes and night
02:20:30.660 sweats are these nuisance symptoms that
02:20:32.520 we will take care of temporarily maybe
02:20:35.160 with a little bit of estrogen
02:20:36.660 progesterone or birth control pill
02:20:38.280 because it’s given a lot or that they
02:20:40.020 pass or is that this idea you know suck
02:20:42.359 it up suck it up
02:20:44.040 doesn’t matter that you’re not sleeping
02:20:45.660 anymore you know turn down the
02:20:47.760 temperature in your room
02:20:49.439 and that’s not right because
02:20:52.080 hot flashes and night sweats are a
02:20:54.359 biomarker
02:20:55.740 of cardiometabolic disease they are a
02:20:57.899 biomarker of increased bone loss
02:21:01.260 they are a biomarker of changes in the
02:21:03.600 brain
02:21:04.620 so many of these symptoms that occur in
02:21:07.020 perimenopause are not driven by the
02:21:09.240 ovaries they are driven by the brain
02:21:11.460 yeah it’s the the bi-directional
02:21:13.859 crosstalk between the body and the brain
02:21:16.200 keeps you know I think is this
02:21:17.399 resounding theme uh we had Chris Palmer
02:21:19.740 on here a psychiatrist who’s talking
02:21:21.359 about ketogenic diet mental health I
02:21:23.399 know uh you we could have a whole other
02:21:25.920 discussion and we will I hope if you’ll
02:21:28.140 agree to it about nutrition and as it
02:21:30.899 relates to hormones uh specific diets
02:21:33.420 and and so forth but the and that’s a
02:21:35.760 question too whether this problem of
02:21:39.359 cerebral hyper metabolism
02:21:41.460 could we solve it with estrogen
02:21:44.399 and or increased metabolic flexibility
02:21:46.920 so I just wanted to footnote that sorry
02:21:49.620 to interrupt you no please uh please
02:21:51.180 interrupt um uh I know Europe as long as
02:21:54.600 we’re there I know you are a fan in some
02:21:56.760 instances of intermittent fasting time
02:21:58.680 restricted feeding and or ketogenic diet
02:22:01.260 yes
02:22:02.580 um to get cells sensitive to insulin
02:22:06.060 which is not to say if I understand
02:22:07.800 correctly which is not to say that women
02:22:10.260 need to stay on the ketogenic diet for
02:22:13.200 long periods of time
02:22:14.520 or intermittent fast for my only time
02:22:16.380 restricted feeding for eight hours or
02:22:17.700 six hours a day but that by increasing
02:22:19.859 you said metabolic flexibility
02:22:22.800 excuse me but by increasing cells
02:22:26.040 sensitivity to insulin and then maybe
02:22:28.260 returning to a more typical eating
02:22:30.060 pattern and periodically switching back
02:22:32.040 and forth that might actually benefit be
02:22:33.780 beneficial do I have that right yeah I
02:22:35.880 love the pulse so I feel like it’s much
02:22:38.399 more physiologic than say going on a
02:22:40.740 ketogenic diet and staying there for
02:22:42.359 years all of the data that we have on
02:22:44.580 the ketogenic diet
02:22:46.200 it’s pretty Limited in terms of duration
02:22:48.300 you know the the longest players that we
02:22:50.819 have in terms of the data are the focus
02:22:53.819 with epilepsy and that’s just a
02:22:55.620 different phenotype so I think in terms
02:22:58.920 of microbiome effects diversity
02:23:00.660 dysbiosis some of those issues we really
02:23:03.479 don’t know in terms of long-term effects
02:23:06.060 so I prefer with a ketogenic diet that
02:23:08.939 it’s used as an NF1 experiment and that
02:23:11.520 to do it for four weeks maybe you
02:23:13.500 measure biomarkers before and afterwards
02:23:15.780 maybe look at your stool before and
02:23:17.399 afterwards we still haven’t talked about
02:23:18.660 stool tests yet but you could measure
02:23:20.819 your fasting insulin and your glucose
02:23:23.460 you could just start there do four weeks
02:23:25.859 of Keto clean keto including vegetables
02:23:28.620 it doesn’t have to be 57 a day and then
02:23:31.500 measure it again afterwards
02:23:33.479 since you mentioned a mentioned stool
02:23:35.700 testing yes
02:23:37.560 what what is your recommendation about
02:23:39.899 stool testing
02:23:42.120 so my recommendation this is again in
02:23:44.819 the the field of if you have the
02:23:47.580 disposable income so I usually start
02:23:49.140 with Genova because they’ve got a good
02:23:51.180 copay system with insurance that’s what
02:23:53.880 I typically use so I usually do their
02:23:55.920 one day stool test where you have to go
02:23:58.260 digging through your stool and send it
02:24:01.680 off to the slab that’s in North Carolina
02:24:04.380 I usually do the one day unless I’m
02:24:06.240 concerned about parasites in that case I
02:24:08.520 tend to do three days I do that for
02:24:09.960 people who travel a fair amount and go
02:24:11.939 to places where there’s greater risk or
02:24:13.920 they just have gut symptoms
02:24:16.920 another test that I do a lot is
02:24:19.740 um because I always like to mention two
02:24:21.060 Labs is a test by longevity
02:24:24.540 and this is much more of a data wonk
02:24:27.720 uh type of test because it’s powered by
02:24:30.420 AI it was designed by
02:24:33.000 um
02:24:33.780 a guy who’s got inflammatory bowel
02:24:36.300 disease and he is a
02:24:40.020 um he’s a PhD
02:24:42.180 deep phenotyping bioinformatics guy who
02:24:45.720 wanted to make this really easy
02:24:48.060 so the test is is Under the Umbrella of
02:24:50.939 thorn
02:24:52.200 and
02:24:53.520 um they just call it got bio they might
02:24:55.020 have another name for it and they just
02:24:56.520 improved it so that it’s just a wipe
02:24:59.040 instead of digging through her stool and
02:25:01.380 so my athletes will do it now they were
02:25:03.300 not so into digging through their stool
02:25:05.160 before is anybody really no one is I
02:25:08.340 don’t want the answer
02:25:09.740 I know the answer I prefer to that but
02:25:12.840 that’s a super interesting test because
02:25:14.640 it’s
02:25:16.500 you get much more dense data the issue
02:25:19.920 is
02:25:20.880 um with apologies to my friends at
02:25:22.620 Thorne the issue is that there are
02:25:25.380 recommendations end up being sworn
02:25:27.359 supplements so that can be very easy for
02:25:29.939 people who want to you know connect the
02:25:32.460 dots
02:25:34.439 that’s not always the way that I like to
02:25:36.240 do it uh first of all
02:25:39.300 three things
02:25:41.340 um
02:25:42.120 you’ve shared with us an immense amount
02:25:44.340 of knowledge and
02:25:47.220 in that first statement I also want to
02:25:49.439 apologize because I threw at you the
02:25:50.939 entire life span of uh female lifespan
02:25:54.000 reproductive Health contraception diet
02:25:56.760 uh microbiome so many things but
02:25:59.939 um I first I just want to say
02:26:02.100 you’ve taught me a tremendous amount
02:26:04.620 um
02:26:05.700 including I think something that most
02:26:08.520 people including myself have not thought
02:26:10.680 about enough which is the psychosocial
02:26:13.080 impact on things that we’re all familiar
02:26:16.260 with
02:26:17.100 constipation bowel movements what we eat
02:26:19.979 what we avoid I have to say really a
02:26:23.819 huge thank you for that because
02:26:26.700 it’s not something that’s been discussed
02:26:28.200 on this podcast before sort of know that
02:26:30.359 brain communicates with body psychology
02:26:32.700 and biology are linked but I think this
02:26:34.380 is the first time that anyone’s ever
02:26:35.760 directly linked
02:26:38.359 circumstances and biology and psychology
02:26:41.040 in such a concrete way so that’s that’s
02:26:43.500 the first thing and I speak for many
02:26:45.540 people in that second of all
02:26:48.180 we barely scratched the surface of your
02:26:50.280 knowledge and um which is both uh
02:26:53.100 frustrating for me because uh it I
02:26:56.220 always want to learn more and I know
02:26:57.300 many other people do as well but also
02:26:59.160 very very exciting because uh with uh
02:27:01.260 hopefully without much persuasion we can
02:27:02.760 have you back on to talk about something
02:27:04.319 at all like meant uh I know you’re
02:27:06.960 working with men now Men’s Health
02:27:09.180 um some particulars around I think
02:27:11.399 there’s more for us to explore in terms
02:27:13.800 of PCOS menopause contraception and all
02:27:16.200 of the above but then something that you
02:27:17.819 and I were talking about off camera
02:27:19.800 um before we started which I think is a
02:27:22.080 really important factor that ties back
02:27:24.120 to this issue of of
02:27:25.979 trauma and stress and the bi-directional
02:27:29.580 relationship between biology and
02:27:30.960 psychology hopefully someday we won’t
02:27:32.580 even separate those two
02:27:34.220 which is the use of specific medicines
02:27:37.439 including plant medicines yes and how
02:27:39.780 that can influence overall health which
02:27:41.580 no doubt will include Hormone Health
02:27:43.800 so I say all of that for two reasons
02:27:46.439 first of all to queue up the
02:27:48.300 we won’t even call it a part two but a
02:27:50.100 sequel to the to this with
02:27:52.500 um I’m gratified to hear that you you’ll
02:27:54.180 join us for that and then also to just
02:27:56.399 really extend a huge thank you the
02:27:58.140 amount of knowledge that you shared is
02:27:59.880 is immense and uh is going to be very
02:28:03.540 very useful and actionable for for men
02:28:06.600 in terms of their thinking and their
02:28:08.580 actions and
02:28:10.380 for women in particular today’s
02:28:12.359 discussion in particular for women in
02:28:14.580 terms of how to think about their health
02:28:16.020 and biology how to think about their
02:28:17.520 psychology and the environment that all
02:28:19.080 of that’s embedded in so I just want to
02:28:20.880 say an enormous thank
02:28:22.920 you thank you Andrew I so appreciate
02:28:24.899 that and I so appreciate
02:28:26.880 what you offer to the world in terms of
02:28:29.460 a weigh-in a way to understand
02:28:31.620 physiology and how to craft a architect
02:28:35.040 a better life
02:28:37.439 um can I just add one last thing because
02:28:39.899 I didn’t talk about it since we didn’t
02:28:41.640 get to the 40s and the 50s and those
02:28:43.620 listed biomarkers so I feel like if
02:28:47.160 people if women went away with one thing
02:28:49.620 today it would be to do a coronary
02:28:52.200 artery calcium score
02:28:54.120 by age 45 and sooner if you’ve got
02:28:56.760 premature heart disease how is that
02:28:58.500 taken so it’s a CT scan of the chest
02:29:01.979 you can self-order it like I think at
02:29:03.960 Stanford Hospital you can self-order it
02:29:05.880 last time a patient checked it was 250
02:29:08.040 so again disposable income but it it
02:29:11.580 tells you it it almost gives you this
02:29:13.740 fork in the road in terms of how much
02:29:16.140 you need to pay attention to
02:29:17.100 cardiometabolic health as a woman and
02:29:19.740 it’s uh 45 for men too so if you haven’t
02:29:22.920 had one if you had one no you need one
02:29:25.760 insulin cortisol CAC great so I’ll run
02:29:29.700 all that by you it’s really essential
02:29:31.560 and it’s um
02:29:34.859 yeah it’s it’s so fascinating because
02:29:38.040 you know there’s some women who have a
02:29:39.840 zero so my score is zero and that’s
02:29:41.880 great so often you can just keep doing
02:29:43.800 what you’re doing but if you’re 45 and
02:29:46.680 you’re starting to be elevated or you’ve
02:29:49.620 got you know maybe you’ve got PCOS or
02:29:51.720 you’ve got some other biomarkers tending
02:29:54.180 you in this direction toward the number
02:29:55.800 one killer really
02:29:58.140 it’s nine out of the top 10 killers in
02:30:00.840 the US
02:30:02.399 that allows you to really start to make
02:30:04.620 changes and I I think it’s essential to
02:30:07.439 know that data it’s not it’s probably
02:30:09.600 not going to be offered by your doctor
02:30:11.460 certainly Peter attia is going to offer
02:30:13.319 it but most conventional doctors are not
02:30:15.540 going to do it and then the last thing I
02:30:17.160 want to say before you mention so if I
02:30:19.080 were to go to my doctor and I just say I
02:30:20.520 want a cardiac calcium score that’s what
02:30:22.800 people coronary artery calcium scores
02:30:25.020 CAC okay so everyone hear that and know
02:30:29.160 that if you’re 40 or older and maybe if
02:30:30.840 you’re 45 45 or older get get it
02:30:34.500 so the last thing is and this is for men
02:30:36.600 and women is there a score
02:30:39.300 so adverse childhood experiences knowing
02:30:42.960 your a score is so essential in terms of
02:30:45.899 a baseline for how much trauma your
02:30:48.840 system your Pine system endured when you
02:30:51.240 were a kid and we know that childhood
02:30:54.060 trauma whether it’s abuse or neglect or
02:30:57.899 you know having an alcoholic parent that
02:31:00.600 maps to disease in middle age and it can
02:31:03.420 give you so much Insight I’ll give you
02:31:04.979 an example I’ve got a patient who had an
02:31:07.200 elevated coronary artery calcium score
02:31:09.000 who does everything right with her food
02:31:11.160 I think it was her trauma that elevated
02:31:13.680 her CAC when she was 45. so I think an a
02:31:18.180 score knowing your a score
02:31:20.939 starting as a teenager like knowing it
02:31:23.340 and knowing how to work with that is
02:31:25.560 really essential there are certain
02:31:27.240 people they are exceedingly rare but you
02:31:29.760 are one such person that when they speak
02:31:31.500 knowledge just comes from comes out of
02:31:34.140 them and it’s incredibly useful and
02:31:36.060 helpful knowledge so thank you I’m gonna
02:31:37.740 get both of those things good
02:31:39.780 um and I highly recommend everyone else
02:31:41.939 pursue ways that they can get those or
02:31:43.740 if they can’t get them that they you
02:31:46.200 know
02:31:46.859 Your Mark those as things to get at the
02:31:49.140 point where they they can obtain
02:31:50.880 sufficient uh disposable income sounds
02:31:53.520 like that the health uh the detriments
02:31:56.939 to health that those can offset would be
02:31:58.800 well worth the cost totally
02:32:01.500 thank you thank you for joining me for
02:32:03.540 today’s discussion all about female
02:32:05.399 hormone Health vitality and Longevity
02:32:07.620 with Dr Sarah Gottfried if you’d like to
02:32:10.080 learn more about Dr Gottfried’s work
02:32:11.640 please check out her social media
02:32:13.200 channels we’ve provided links to those
02:32:14.880 in the show note captions in addition
02:32:17.220 please check out one or all of Dr
02:32:19.560 Gottfried’s excellent books that she’s
02:32:21.479 written about nutrition supplementation
02:32:23.220 and various treatments for Hormone
02:32:25.260 Health longevity and vitality we’ve
02:32:27.660 linked to two of those notably women
02:32:29.520 food and hormones and her book the
02:32:31.439 hormone cure in our show note captions
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02:33:58.680 today’s episode and on many previous
02:34:00.180 episodes of the huberman lab podcast we
02:34:02.160 discuss supplements while supplements
02:34:04.020 aren’t necessary for everybody many
02:34:05.580 people derive tremendous benefit from
02:34:07.020 them for everything from sleep to focus
02:34:08.700 to hormone regulation the huberman Lab
02:34:11.460 podcast is happy to announce that we
02:34:13.080 partnered with momentous supplements
02:34:14.520 because momentous supplements are the
02:34:16.080 absolute highest quality also they
02:34:18.720 include many single ingredient
02:34:19.800 formulations which is essential if you
02:34:21.780 wanted to design a supplement regimen
02:34:23.280 that is both cost effective and the most
02:34:25.380 biologically effective supplement
02:34:26.939 regimen that’s very hard to do with
02:34:28.979 blends of supplements it’s very
02:34:30.600 straightforward to do with single
02:34:31.859 ingredient formulations also momentous
02:34:34.439 supplements ship internationally which
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02:34:37.260 many of you reside outside of the United
02:34:39.000 States if you’d like to see the
02:34:40.439 supplements discussed on the huberman
02:34:41.580 Lab podcast you can go to live momentous
02:34:44.220 spelled ous so that’s livemomentis.com
02:34:47.060 huberman thank you once again for
02:34:49.620 joining me for today’s discussion all
02:34:51.300 about female hormone Health vitality and
02:34:53.760 Longevity with Dr Sarah Gottfried and
02:34:56.700 last but certainly not least thank you
02:34:58.740 for your interest in science
02:35:00.160 [Music]