3 to 75% of women do not get the

treatment for pmenopause and menopause

that they deserve. And women are asking,

why is it that I can't manage stress the

way I once did? Why do I have this belly

fat that appeared out of nowhere and my

usual techniques for how to deal with

that aren't working? Why would I rather

mop the floor than have sex with my

husband? But there's more than 100 plus

symptoms that women aren't aware of. But

you believe many of the symptoms of

menopause are avoidable. Yes. And let's

get into that. Dr. Sarasal is the

Harvard trained physician and hormone

expert who's unlocking the science and

simple tricks behind feeling your best

no matter your age. Most people have

imbalanced hormones. Think of them as

text messages that your body sends to

keep everything functioning optimally.

But for example, out of the 40,000

people I've tested and treated, around

90% of them have a problem with their

cortisol hormones. And if my body's

making too much cortisol, what is the

harm? It's associated with more belly

fat. We know that it shrinks the brain

in women but not men. It's associated

with depression, but also if you're

someone who's making a lot of cortisol,

you're going to make less testosterone,

and that leads to a whole host of

serious problems. And what about trauma?

Does that impact your hormones? Oh, yes.

And one of the ways to measure trauma is

the ACE test. It's a validated

questionnaire, and they found that

people who had one or higher ACE scores

had a greater risk of 45 different

chronic diseases. And my score is 6 out

of 10. But those ACEs are living on in

your body. And you went on a journey to

heal yourself. Yes. With lifestyle

medicine, not a pharmaceutical. Tell me

about that journey.

This has always blown my mind a little

bit. 53% of you that listen to this show

regularly haven't yet subscribed to the

show. So, could I ask you for a favor

before we start? If you like the show

and you like what we do here and you

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everything in my power, me and my team,

to make sure that this show is better

for you every single week. We'll listen

to your feedback. We'll find the guests

that you want me to speak to and we'll

continue to do what we do. Thank you so

much. Dr. Sarah Zal, what is it that you

do for people? I'm a

physician, so I work in academic

medicine. I do research for people. I

teach and I take care of patients. So

that's the official BBC answer. And the

unofficial answer is I'm a healer. And

what does that mean, a healer? Because

that's a broad term. So that could mean

many things.

It means that my

task is to connect to your innate

healing

capacity and to work with you to

activate it. And who do you do that for?

So I do it for professional athletes,

executives

and everyday people. And when you say

healing, if someone came to you and they

said, "How do you heal people?" What

would your answer be? My answer is I

don't heal people. That's

uh to me that's a patriarchal way of

thinking about it.

What I do is I work with someone who's

got the capacity to heal and we work to

be in the service of that. So it's not

me providing something that they don't

have already. It's more understanding

what some of the obstacles might be to

their own healing. Understanding what

would allow them to be the best version

of themselves to feel fully alive. And

what was your training? So can you talk

me through your sort of academic

journey?

Sure. So my training is as a

bioengineer. I did the Harvard MIT

program which is designed to train

physician scientists.

So the um ethos of this particular

program was to train the future

researchers and um academic

physicians so that we could move the

field forward. And all along I was

really interested in how do you bring

the best of conventional medicine

together with more ancient ways of

thinking about the body? things like aya

from India or uh traditional Chinese

medicine. How do we take these wisdom

traditions and use that to inform

mainstream medicine? So that's the type

of care that I learned how to do. I

became a

surgeon. I did primary care after I

finished a residency in obstetrics and

gynecology. But I also realized pretty

early on that I wanted to take care of

men, too. So I've done that for about

the past 15 years and I would say that

that training in bioengineering and a

comfort with big data and with um

optimizing data sets to improve whatever

the goal is like performance or having

the most the best conversations you can

have on a

podcast. That's what gets me excited.

How many people do you think you've

treated or seen or worked with directly

in your career? Probably about 40,000.

And and if you had to try and summarize

maybe the top three or five things that

you're doing for

them, what would you say? Well, number

one would be

hormones. Hormones are the portal that

most people start with me. Um, it's a

way of thinking

about what drives what you're interested

in. Most people have imbalanced

hormones. I haven't detected that you do

yet, but most people have an issue, say,

with cortisol, either making too much of

it or too little or even both within the

same day. And it affects energy. It

affects mitochondria.

So I would say the number one thing I

help people with is their hormones.

Getting their hormones back into

balance. Starting first with lifestyle

medicine, not a pharmaceutical. So that

includes breath work, which I think is

one of the most

underutilized tools that we have in

health. Number two would

be nutrition, but taken to the next

level. not what you might think of that

a nutritionist would advise you, but

what specifically is the ideal food plan

for you for your goals. So whether

you're a entrepreneur and podcaster, an

investor, or you're a professional

basketball player, or you're a woman in

pmenopause at age 42, what's the optimal

nutrition for you? And we can measure

that and we can look at the interaction

of your

genetics together with what you're

eating to see how we could personalize

that. Number three I would say

is

prevention. And prevention has been a

hard thing to sell. It's um you know a

lot of people just don't want to invest

in prevention and yet I take care of

people who are in this continuum from a

state of health often to a state of pre-

disease like pre-diabetes as an example

and if they don't do something about it

they then move on to diabetes. So I like

to intervene there as early as possible

to reverse

disease and most of that is

lifestyle. So those are the things that

I tend to work with. I do a lot of

metabolic health because it's so

critical for the energy that you feel

each day. You have a very diverse

experience as a doctor/healer.

feels like you've really had a lot of

sort of reference points in your career

that you've drawn upon and ultimately

you became the director of precision

medicine at the Marcus Institute in

Philadelphia. That's correct. Precision

medicine, that term. How does that

differ from conventional medicine?

It's quite different. So, conventional

mainstream modern

medicine I believe is broken. I feel

like there are so many people who are

failed by our current medical system,

especially people with chronic disease,

things like diabetes, autoimmune

disease. So

with mainstream medicine, generally what

happens is that you develop a condition,

say a high cholesterol, and you get

treated with a pharmaceutical, say a

statin. And what we know is that we have

to treat about 100 to 200 people for one

person to benefit. So that I would

define as imprecision medicine. Whereas

precision medicine is where we

understand you as an individual. We look

at your genomic blueprint. We look at

your biomarkers. We look at your

wearables data to

determine NF1 experiments where you

serve as your own control and figure out

what's going to be the most effective

for you depending on what your goals

are. NF1 you mean where that individual

is the study, they are the experiment.

That's correct. You're not looking at

broad sample sizes. What is wrong with

conventional medicine? You use the term

that it's broken. What is wrong about

that approach?

There's a few things that are wrong. One

is

that it has become medicine for the

average. And when you look at scientific

evidence and you rank order it, what's

considered the highest form of evidence

is the randomized trial. But the

randomized trial is mostly around using

a pharmaceutical. So, in the example I

just gave, using a statin to help

someone with their cholesterol, maybe

help prevent a heart attack, the number

one

killer. The problem is we then based on

randomized trials come up with medicine

for the

average. And it's not

about optimal health. It's not even

centered around health. It's centered

around, okay, heart disease, number one

killer. How do we help people prevent

it? Oh, lifestyle medicine prevents 70%

of it. Well, we're not going to do that

because we can't make money off of it.

There's no profit motive. So, we're

going to focus instead on these

pharmaceuticals. Oh, GLP1s. That sounds

like a good idea. Let's try that and

solve problems with GLP1s.

So to me, there's many layers to why the

health care system is broken, but one

key area is that 70% of the diseases

we're facing right now are utterly

preventable with lifestyle medicine.

70%.

You used the word hormone balance

earlier on. Um, and you said that that's

the portal in which people often find

you. I really don't know much about

hormones and it's not necessarily

something that the average person thinks

that they can do much about I think

because it's not easy to measure our

hormones is it? Well, you can measure it

in the blood. So, it's it's not that

hard to measure hormones but I think

there's there's a way that in mainstream

medicine we're taught to tell people

that their hormones vary too much and so

it's not worth measuring. Yeah, that's

what I've heard before. It's what you've

heard. But then if you're a woman who's

34 and you're trying to get pregnant and

you're having trouble in that situation,

we'll measure every single hormone.

We'll look at thyroid, cortisol,

testosterone, estrogen, progesterone,

the control hormones like follical

stimulating hormone. And

yet somehow in that situation, testing

is more reliable, but it's not in this

other situation. That doesn't make

sense. That's double standard. Why did

you choose this career? What What is it

about you, your childhood, your life

that sent you down this road? I would

say it was growing up with a fair amount

of trauma.

And you know the what I've learned about

trauma is it's less about what actually

happened to you. It's the way that it

became embedded in the system of your

body. So for me, my parents got divorced

when I was really young. I grew up in a

way that I became a helper. And I

realized that by being

um someone who was really looking out

for others and tuning into their energy

and helping them achieve their goals

that kept me really safe. And so there's

a way that

that it was very resonant for me to

discover medicine.

And one of the things we know about

people who go into medicine is

that people tend to have a fair amount

of trauma that leads to becoming a

helper in this way. What was that

trauma?

So there's a lot of different ways to

measure trauma. One of the ways that I

find helpful is something called the

adverse childhood

experiences. So ACE for short. I think

I've got it here. Oh, do you? It's a

questionnaire. So my score is six out of

10. So childhood divorce, my parents got

divorced when I was about a year old.

That's one out of the six. Other things

are abuse, neglect,

um emotional abuse, physical abuse,

having a parent with a substance use

disorder. So things that you know it's

not a complete list but it's a validated

questionnaire that was used in the

1990s and found among people who are

middle-aged you're not quite yet

middle-aged but for people who are

middle-aged 40 to 65 they found that

people who had higher A scores one or

higher they then had a greater risk of

45 different chronic diseases.

How important is it for us to understand

our early upbringing and our trauma if

we are to heal as adults? Because you

said there that if you score high on

this ACE score, this trauma score, this

childhood trauma system sort of

questionnaire, then as an adult, you're

more likely to get a variety of

different diseases. So, do we need to

heal our bodies in some way to avoid

getting some of those diseases? Yes. And

that's the critical question.

So if you know that you have an elevated

A score and there's a lot of people who

have a score of zero about 40% of men

about 30% of

women and what we know is that if you've

got this greater risk for 45 different

chronic conditions there's a way that

those ACEs are living on in your

body unless you're addressing them. And

it's the living on in your body that we

want to pay attention to. So for some

people it's their immune system and it

leads to more allergies, more histamine

overload, more um food intolerances,

maybe

autoimmunity where their immune system

is attacking their own tissues, maybe

autoimmune disease. There are other

people who have more nervous system

dysregulation. Maybe they've got anxiety

or depression or post-traumatic stress

disorder, mental health issues. And for

other people, it could be more

endocrine. They've got chronic cortisol

problems, which is hormones. Yes.

How did that manifest in your physical

health? So, I didn't start to detect

this until my 30s. But what I found was

that I

had

depression. I had premenstrual

syndrome. I had my first baby when I was

32 and I couldn't lose the baby weight.

And as all of this was happening, and

I'm a physician, I went to my doctor for

help. And he suggested that I go on

Prozac for the depression and the mood

issues, which is an anti-depressant

pill, a selective serotonin reuptake

inhibitor, that I go on the birth

control pill because I sounded hormonal,

and that I start exercising more and

eating less. So that was his treatment

and that's typical mainstream medicine

treatment. But I wasn't satisfied with

that. I felt like that doesn't seem

right. And I left his office and went to

the lab, ordered my own hormone panel

and found that my cortisol was three

times what it should have been. So

there's the optimal range for cortisol

in the blood. It's about 10 to 15 in the

morning, 6:00 to 10 in the afternoon.

And mine was 30.

I also looked at my fasting glucose and

insulin and I had pre-diabetes in my

30s. I had no idea. No one was checking

for this. So, I'm answering your

question about how these ACEs showed up

in my body. We know that adverse

childhood experiences linked to blood

sugar problems and a greater risk of

pre-diabetes and diabetes, which I had.

We know that they linked to chronic

stress and cortisol problems, high

perceived stress, whether the stress is

there or

not. It also led to as I started using

wearables, low heart rate variability,

the time between each of my heartbeats.

And that's a measure of the sympathetic

nervous system, fight, flight, freeze,

fawn, versus the parasympathetic nervous

system, which is where healing occurs.

And you went on a journey to heal

yourself. Yes. Tell me about that

journey.

So in my

30s, this is a huge epiphany for me

because I realized that I wasn't

trained. I wasn't

educated, even though I had an

outstanding education, I wasn't trained

to help with

this. No one taught me about cortisol

problems and how to manage that. I mean,

I was taught about the extremes of

Cushing disease- which is really high

cortisol levels and Addison's disease,

which JFK had, and it's when your

adrenals in your back above your kidneys

don't make cortisol. So, I was taught

about the extremes, but I wasn't taught

about all the people who kind of live in

the middle with problems with their

cortisol. So this is when I started to

take the scientific literature and apply

it to my

situation because I wanted to feel

better. I felt old before my time and I

had a lot of belly fat and I was on this

path of aging at an accelerated clip. So

I did it to help myself but then I also

wanted to help my patients and it felt

like I needed to go deeper and

understand what can we do to treat the

trauma and also to treat the more uh

proximal measurements that we're making

like with cortisol with heart rate

variability with blood sugar.

So what was step one for you?

Step one was awareness. Okay. And I had

no idea. These are not things that most

doctors are checking for. It's pretty

crazy that you're a doctor, but you

don't know this part of

health. I mean, how are you going to

help anybody if you don't fully

understand health from a more sort of

holistic perspective? That's a critical

point. So, I was taught at Harvard that

if you have blood sugar problems, if

you've got pre-diabetes and

diabetes, the treatment is lifestyle.

It's the most effective to change the

food that you're eating, to increase

your exercise, to um manage your stress

in a different way. And yet, I wasn't

taught how to help my patients do any of

those things. I was taught how to

prescribe a medication for it like

metformin or some other treatment but I

wasn't taught how to do lifestyle

medicine. I had 30 minutes on

nutrition. So yes, it is pretty crazy.

They gave you 30 minutes on nutrition.

Yes. During which training? This is

medical school and I got about the same

amount on pmenopause and menopause.

Really? I mean that explains a lot. Yes,

it does about the medical system. So

step one was awareness. What was step

two? Step two

was what does the science tell

us? And if we take what the science

tells us, usually applied to a

population, that then sets us up for

step three, which is end of one

experiments, trying things on yourself

and then measuring. That's right. When

we think of cortisol, which was the

first sort of marker that you saw was

elevated, we think of stress. So, we

think we get cortisol if we're stressed.

So, my brain, my my very naive brain

said, "Well, you just need to be less

stressed,

Sarah. So, you should just go on holiday

and then your cortisol will come down."

I used to think that, too. And then I

would come back from the holiday and I

would still have cortisol problems.

So stress is part of it, but cortisol is

really interesting. These hormones that

we're talking about, estrogen,

progesterone,

testosterone, cortisol, insulin, it's

not a democracy. Like they don't have

equal footing. Cortisol is more like a

dictator, especially if it's out of

whack. So you need cortisol to live.

Whereas you could live without

testosterone, estrogen, progesterone.

can't live without insulin. But cortisol

is critical in terms of helping you with

your immune system, helping you with

your blood sugar, and just managing the

stress response. So, it's not quite as

simple as thinking your way out of a

high cortisol or a low cortisol. And

there are ways that your body can become

stuck in a particular pattern of making

too much cortisol or making not enough

cortisol.

And if my body's making too much

cortisol and my levels are too high,

what is the what is the harm? The harm

is it's associated with

depression. It's about 50% of people

with high cortisol. 50% of people with

depression have high cortisol. It's used

by some

psychiatrists as a suicide

marker. It's associated with more belly

fat. And so the fat receptors, the fat

cells in your belly have increased

receptors for cortisol. So it's a way of

growing your belly fat. We know that it

shrinks the brain in women, but not men.

starting in midlife, starting in your

40s. It's not an old age thing. And this

has been shown a couple of different

ways. There was a study from the

University of Texas in San Antonio

showing that women in their 40s with

high cortisol have a shrinkage of total

brain volume. And then Lisa Moscone at

Cornell also just showed in a study

looking at men and women that women with

high cortisol also have shrinkage of

their total brain volume. and they start

to have a difficult time using glucose

as fuel in their brain,

which is going to result in what kind of

behaviors? Well, it makes you tired. It

gives you slow brain

energy. And I can tell for the most part

you don't have that. But if you do have

it, there's a way that you kind of your

brain slows down. You feel foggy. You're

not able to multitask and kind of keep

up keep up with everything. Is there a

link between cortisol and uh trauma? Oh

yes.

What is that link? So for people who

experience toxic stress or trauma, what

typically happens is cortisol goes up.

That's part of the alarm. Yeah. The

body's stress response. What we know is

that for people who've got more serious

exposure to trauma and they have

post-traumatic stress

disorder, those people have probably

gone through a period of high cortisol

and now they can't keep up anymore and

they are in a low cortisol state.

What are the things in in the world at

the moment that are messing up our

hormones? because the subject matter of

hormones has become increasingly popular

and I know that there's hormones like

cortisol which we've talked about um

testosterone, estrogen, progesterone, um

insulin, glucose. What are the what are

the big things that are like messing up

our hormones at the moment if if I

because I want to make sure my hormones

are in check. Um so I'm a guy. I'm sure

that there's you know some of these

hormones are more like things like

estrogen have I think more pertinent to

women but No, it's important for men

too. Oh really? So estrogen and

progesterone are incredibly important

for men and it's, you know, it's

involved in uh bone

strength. Progesterone is involved in

sleep in men. So the levels are lower in

men and your testosterone is about 10

times higher. But in women and men,

they're all

important. So what's messing with our

hormones? I would

say toxin

exposure. So there's endocrine

disruptors. There's more than 700 known

endocrine disruptors. Things like

bisphenol A um like the plastic lining

that you see in cans or in uh plastic

containers, water containers. There's um

skin care products which women are

exposed to more things like moisturizer

and makeup and other things that contain

um endocrine disruptors like parabens

and

um there's flame retardants that we get

exposed to. So there's a whole class of

endocrine

disruptors and

then it feels right now like we are more

disregulated than I've ever

seen. And I'm not

sure what the cause is. I don't know if

it's the

post-pandemic experience or part of what

we're experiencing in the United States

with the change in leadership.

It just feels like there's this hum of

dysregulation that I haven't seen over

my career.

Are you noticing that? Are you seeing

that in your patients? And I see it in

my patients. I see it in their wearable

data. I see it in heart rate

variability. I see it in the cortisol

levels that I'm measuring.

You asked if I'm noticing that. I mean,

the more digital the world has become, I

think I've seen more dysregulation, and

we're obviously moving further in that

direction at rapid speed, especially

with things like AI now and

um algorithms getting more smart and

addictive. Yes. So, I I see that. Also,

there's just been a change

in I think the algorithms, the social

media algorithms will compete with

themselves to to see who can hold you

the most. And to do that, they have to

kind of grab your attention. and the

easiest ways to grab your attention is

by showing you things that are probably

disregulating. Yes, it's an attention

economy and the cost in that fight for

attention is that often the nervous

system becomes more disregulated.

So, if you had to come into my life and

you had to optimize my life to make sure

that all my hormones were in check, you

would get rid of plastics and and toxins

from my everyday life, my bathroom, um,

etc. I'd look at your skin care. I'd

look at your cleaning products. I'd look

at your air

quality. I'd probably install a couple

of air filters if you don't have that.

I'd want to know about your stress

because you're someone who performs at

such a high level and I would assume

that you found the right level of stress

where it's not so little that you're not

productive but it's not to excess to the

point that there's a cost to it

physiologically.

Yeah. And then and I'd want to look at

your food. I'd want to know how much

protein you're consuming. Are you

getting the right amount of

carbohydrates? Seems like you are. Are

you utilizing those well? What's going

on with the continuous glucose monitor?

How are your nutrients? What's your

vitamin D? Things like that. You're a

big fan of continuous glucose monitors,

aren't you? I am. I think it gives

real-time feedback, immediate feedback

on the food that you're eating. I've

seen nothing else change behavior like a

continuous glucose monitor. And for

anybody that doesn't know, it's the

little patch you put on your arm and it

tells you your blood sugar levels in

real time straight to your

phone.

Sugar, is sugar the

enemy? I don't think sugar is the enemy.

I think the enemy

is the way that we eat it to access, the

way that we use it to change our

emotional state.

And we know people who have adverse

childhood experiences, they're more

likely to have disordered eating.

They're more likely to have problems

modulating the amount of sugar they

consume. When you're treating patients,

do you focus heavily on their blood

sugar levels? I do because I think it's

an important indicator of the way the

biochemistry of the body, the metabolism

is working. It tells me about their

mitochondria. It tells me about the way

that they're producing

energy ATP by ATP. This compound, this

um this measure of energy that you

produce inside of all of your cells,

which is called ATP. ATP.

And that ATP then drives what? It drives

our everything we do. ATP is fuel. So,

it allows you to feel like you're fully

energized, especially when you wake up

in the morning. And are there any

supplements that I should be taking if

I'm trying to optimize my hormonal

balance? Well, I'd have to look at your

total picture, but most of us

inherit somewhere around 5 to

seven genomic

um vulnerabilities and often we want to

work around those. So for instance, for

me, my vitamin D receptor sucks. It just

doesn't work very well. So I have to

take increased levels of vitamin D to

keep the um kind of the baseline amount

of vitamin D in my system normal. So we

would want to look for those. We'd look

at your genomics to

see what's your relationship to B

vitamins. With the stress that you

manage, do you have a a deficit with B

vitamins? For a lot of men, it doesn't

show up until around age 40. So, this is

a good time for you to do a baseline.

When you look at people's biomarkers and

their blood samples, what are the things

that you like typically always see that

are deficient? Because I'm sure there's

things from a social level that we're

just all kind of getting wrong.

Vitamin D is common. So, somewhere

around 70 to 80% of people don't have

enough vitamin D. And one of the things

that I think is so important to realize

about vitamin D is that it's got 400

jobs in the body. One of them is keeping

your boundary in your gut intact. So

keeping tight junctions working so that

you don't have leaky gut. So vitamin D

is a common one. I had an executive that

I took care of on Tuesday and he had a

fasting glucose of

102, which is in the pre-diabetes range.

No doctor has pointed this out to him

before. He had uh his cholesterol was

starting to climb. His blood pressure

was borderline, not high enough to

require a medication,

but at the point where we want to turn

that ship around before he needs a

medication. He had a level of

inflammation in his

body that was causing aches and pains

and

um kind of like this silent condition

that um wasn't working well for him. So

there's a couple ways to measure that.

For him, his homocyine was elevated. It

was

14.7. And that's a that's one that's

really easy to measure in a basic panel.

What we want with homoyine, which is um

heart specific inflammation, we want

that to be 5 to 7. And when it's

elevated, that tells us that often part

of the biochemistry in the body, your

methylation is not working well.

Methylation is just where you add a

carbon and three hydrogens to a

molecule. And it's a way that we turn

uh genes on and off. And so in this

person's case, he wasn't getting enough

B vitamins, methylated B vitamins. So we

started him on a supplement to help him

with that. So that's a common one. His

testosterone was good, so didn't have to

address that. This guy was about 52.

Um, his cortisol was good. He was the

chief financial officer of a company

back east. Well, he had a number of

things on his genomics that we needed to

pay attention to. What was interesting

about this guy, Steve, is that he was an

athlete. He played football in high

school and college. He had this identity

as an athlete, but when he came to see

me at age 52, he was barely exercising.

He would lift weights maybe once a week.

He would go swimming for about 30

minutes once a week. And so he wasn't

leveraging disposal of glucose the way

that he could be, the way that he used

to when he was in his 20s. So a big part

of understanding what made him tick was

to reaffirm this identity as an athlete

and to use that to address this

metabolic crisis that was starting to

happen in his body before it was too

late

cuz he's got too much glucose and he's

not doing enough with it. That's right.

So his body is having to store it and

getting inflamed.

and he said, "You know, listen, it's

been the Christmas holidays. I had a lot

of pound cake. I had some cocktails. You

know, maybe that's part of the problem."

But we had measured his hemoglobin A1C,

which is a threemon summary of what's

happening with your glucoses. And the

problem predated Christmas. So, we

needed to get them into action around

exercise. Getting back to hormones, I

really want to um close off on this

subject of cortisol because I know that

that's such a important hormone. I've

heard you say before that you believe

that uh cortisol is the most critical

hormone to get into balance. You want to

focus on cortisol really first and

foremost. So, someone like me, is there

anything else I need to know to get my

hor my cortisol levels in balance? And

also, what percentage of the population

do you think have their cortisol out of

whack?

H so we don't have data on the numerator

or the

denominator and my patient population is

enriched with people who've got cortisol

problems. So out of all of the people I

test, somewhere around 90% of them have

a problem with their cortisol. And that

includes professional

athletes because at least in the US like

basketball

players, they travel a ton. They play

backto-back games. They've got a

cortisol load, a stress load that is

pretty high even for someone in their

20s or 30s who's used to high

performance. So the number is high. If I

had to look at the general

population, it would be a total

speculation. I would say somewhere

around 30 to

50%. And what do you do about that? If

you're an athlete and you've got

elevated cortisol levels,

I think there's a number of different

things. There's the top down approach,

which is cognitive kind of like what is

my prefrontal cortex? How can I leverage

that to work with this? And then there's

more of a bottomup approach which is

using your senses to create safety and

to change the cortisol signal kind of

the alarm in the way that it goes off in

the body. So breath work is really

important for that. Meditation

um different forms of

movement dancing you know rhythmic

movements walking hiking.

Running's a little tricky because um

that can be a stress response and it can

raise

cortisol. Um so I would say for a

professional

athlete, what I usually recommend is um

meditation, regular meditation, and

finding what's a really good fit for

them. Because, you know, for some

people,

mindfulness-based stress reduction is a

good fit, but that doesn't fit for

everyone. Other people like resonance

breathing, like a 5-second inhale,

7-second

exhale, six breaths per minute. Doing

that for 10 to 20 minutes. That can

really help to create balance between

the parasympathetic nervous system and

the sympathetic nervous

system. For some of my athletes, it's a

supplement. So if they've got high

cortisol, one of the things I often do

is to give them cortisol manager, which

is a supplement that includes

ashwagandha and phosphatidal serereine.

And it's been shown to lower cortisol

levels. So if they're traveling and they

have to take a plane back to

Philadelphia after an away game,

cortisol manager can help them manage

the cortisol. I found a supplement

called I can't pronounce the name

properly, but riol. Oh, rodeiola.

Rodeiola. Yes. Rodeiola is an

adaptogen. So, it's a it's an herbal

therapy that's been shown to help with

cortisol. Lowers cortisol. Yes. And I

was reading that it increases your focus

potentially. Yes, it does. Do you

prescribe that to athletes? I do. So,

generally what I try to do with most of

my athletes is have them take a

supplement either first thing in the

morning or before they go to bed. It's

harder to do it during the day. And so I

tend to start with cortisol manager

because I think it's got the best data,

but rdea is also a good choice and I

have prescribed that. Is it easy for

people to change in this regard to get

them to make a set of different

decisions? I think we're at a time of

year where a lot of people are thinking

about changes and a lot of people are

failing repetitively every year at the

changes they say they want to make. Is

it easy to get someone to change? I

would say behavior change is the hardest

thing that we do as humans. I think

there are ways that

uh adverse childhood experiences tend to

set a pattern that's very hard to break.

But I see people change their behavior

all the time. And I think part of it

depends

on what's the pain of staying the same.

if it's high enough to motivate you and

to help you, you know, not take the shot

or two of tequila that has been your

downfall in the past. If um you have

something that keeps you accountable and

has like the Hawthorne effect, like a

continuous glucose monitor, I think that

can also be very helpful as if someone

was watching you because my patients

with their continuous glucose data, I am

watching them. I'm scanning them.

But does doesn't that mean that in order

to change, some people just need a bit

more pain?

I would say people have a different

level of pain that motivates change.

Have you ever seen a situation? We were

talking about this a couple of couple of

weeks ago where when you're trying to

help someone, you actually end up

propping them up and because you're

intervening to stop them experiencing

the pain that they might otherwise, you

end up harming them because you're

preventing them from going to that place

where, you know, they call rock bottom

where self-motivated change would occur.

It's a good question. I think there's

there's a fine line

between motivating and also speaking

your truth about what you're willing to

tolerate, say in your partner or a

friend or family

member, and also enabling or

[Music]

um being

codependent. And so you have to try to

find that line. I mean, one of the

things I found over my career, and it

took me a while to learn this, is that

if someone has denial about what they're

doing and how it's affecting their

relationships, their health, their

ability to work, say, drinking too much,

having a sticky relationship with

alcohol, it's not my job to break

through their denial. They have to do

that. That's their work. Now, I can

say alcohol has no health benefits.

Here's what it does. Here's what it does

to the female brain. Here's what it does

to the male brain. Here's what it does

to um break the boundary in your gut and

cause leaky gut. Here's all of the

unoured effects of it. But it's not my

job to break through their denial. They

have to do that.

And that's very hard especially if you

have a family member or a a friend or a

partner who is doing things that are

harming themselves. So what do you

consider your job to be if you are a

friend or a family member?

Your job is to determine what your

boundaries are, what you're willing to

tolerate to stay in relationship.

And that's, you know, that's where

interventions play a role, where you

confront the person and

say, "I'm really worried about you.

Here's what I'm witnessing. I really

feel like you need to approach this in a

different way. Are you willing?" But

it's a consenting process. You don't do

it for them.

What's your experience?

Well, I just I just have so many, you

know, because these days I can help

people a much more than I could 10 years

ago, whether it's financially or in

other ways. And so, it's often tempting

when someone in my life is struggling in

some way to just intervene with some

kind of crutch. Yes. And I've actually

seen over the last like 15 years that

the best things that I've ever done for

some of my friends wasn't an

intervention. It wasn't paying for

something for them or taking care of

something for them. It was being honest

with them and

then being there as they figured it out

themselves. And often it was actually

removing my crutch which meant that they

would fall a little bit and then climb

themselves out of the ditch to a very

good life. So, I just always think about

that that a lot of us through love or

through the fact that we can often end

up propping people up in our lives and

we're actually doing them a disservice

because we're kind of inhibiting their

own natural growth journey. I agree with

that. And I would I would also say that

what you just described is holding a

mirror to someone in a way that is very

loving but also clear. It's a clean

mirror and it's very different than just

loaning them the money. Yeah. And then

being there for them as they stumble and

struggle and try to make things

different. You you talked earlier on

about the executive that you checked um

recently. You said his testosterone

levels were intact. Yes.

At what age should I be thinking about

my testosterone levels or should I be

thinking about them all the time? cuz I

kind of see it as something that I need

to worry about when I'm when I get a

little bit older into my 40s and 50s.

It tends not to decline until about age

40, but I would say do a baseline now.

Okay, so a baseline biomarker assessment

would be

worthwhile. And you know, one of the

things we found during the pandemic was

that um the National Basketball

Association was playing in a bubble.

They were playing in Florida and the

players cut off from their families and

kind of stuck in Florida for a period of

time. They had low testosterone levels

and these guys normally have pretty high

testosterone levels.

So, there can be specific situations

that can affect your testosterone level.

What was it that was affecting those?

Part of it was just

being in a hotel, in a bubble, unable to

leave, cut off from their community,

their family, their friends, their usual

ways of blowing off steam. I imagine

they're they didn't measure their

cortisol, but I imagine it was probably

higher than normal. And women have

testosterone, too, but you said, I think

earlier, that men just have 10 times

more testosterone. Men have more, but

it's the most abundant hormone in the

female body. Women are exquisitly

sensitive to it. It's the most abundant

hormone. Yes. Higher concentration than

estrogen or progesterone. About 15 to 70

nanogs in a woman. That's what I read on

WebMD. Yes, that's that's a pretty good

level. And in men, 300 a,000 nanogs.

Yes. I like to see it somewhere around

500 to a,000. And what would be

a sign that I had low testosterone if

I'm a man?

Belly fat.

Gynecomastia. What's that? That's when

you have breast development. Okay. mood

changes, mood swings, uh irritability,

uh

depression, cardiovascular changes,

erectile dysfunction, decreased libido.

What about in a woman? So, if a woman

has low testosterone, what are the

symptoms we see in a woman? They're

similar. So, um both sexes have fatigue.

That's very common. Decreased libido.

They might be working out at the gym and

not seeing a response. They might have

some hair

loss. And testosterone in women has a

few unique features. Like one of the

things we've seen looking at MBA

students, students who are getting a

masters in business administration is

that the women with higher testosterone

tend to be more comfortable with

financial

risk. I believe it also tracks with

confidence and agency. We have less hard

data on that. But those are some of the

things that I see. It's a hormone of

vitality in both men and women. So if a

woman is low testosterone, she might be

less confident, have less motivation,

less agency, less willing to take risks,

less sex drive. What if she has high tes

testosterone levels? Too high. So high

testosterone tends to track with

polycystic ovary syndrome. It's the most

common hormone imbalance that women

have. It leads to

infertility. Um it leads to increased

hair growth in places that you don't

want it. So that can include like your

chin and between your

breasts. It can lead to

um insulin resistance in some but not

all but somewhere around 70% of people

with PCOS have insulin

resistance. So it leads to symptoms of

excess androgen, acne, heretism.

It also is associated with problems with

the

mitochondria. It's also linked to

disregulated stress

response. That's something we see with

people with PCOS. So, if I'm a man or a

woman and I want to get my testosterone

levels in order and I don't want to

inject myself with testosterone, are

there natural ways, easy ways for me to

get my testosterone balanced?

It depends on how off it is. First place

to start is your cortisol because

cortisol has this

um interdependent relationship with

other hormones. So if you're someone

who's making a lot of cortisol, you're

going to make less testosterone. So

someone who's got a high level of

stress, like I was talking about the NBA

players in the bubble, maybe their

stress was high and their cortisol was

high and that was why their testosterone

was lower.

So then if I'm a woman with polycystic

ovary syndrome and my testosterone is

high, doesn't that mean I want to

increase my

cortisol? No. In that

situation, what we know is that food is

probably the most important factor with

someone with PCOS. And inside of 7 days,

by eating a lower carbohydrate diet, you

can change your testosterone level. So

you can lower it significantly within

seven days. within seven days. So,

exercise. I'm currently eating like a

ketogenic diet, so my carbohydrate level

is extremely low. Does that mean my

testosterone levels are going to be low?

Not necessarily, because you're not

someone with PCOS. So, it's not quite

translatable across sex and gender. But

for you, with a ketogenic diet, what we

typically see is that insulin levels are

lower. So, it does seem to help with

metabolic health.

It can cause some thyroid dysfunction.

So, it's worth tracking thyroid. We know

that people on a ketogenic diet

sometimes have increased inflammation.

There are some people who are super

responders and they just do super well

with ketogenic diet, but some people

have about a 10% change in their LDL,

their so-called um bad lipoprotein. So,

if you stay on it for more than four

weeks, I generally recommend that you

look at some biomarkers.

Let's talk about estrogen then because I

I was under the impression that um only

women had estrogen, but you're telling

me that it's an important hormone for

men as well. It is. Why is it so

important for for both sexes? What does

it do? Well, I would say it's more

important for women because it regulates

the entire female body.

So we have estrogen receptors throughout

our body. Um when women there's two

different life stages where estrogen is

low. The first is

postpartum. So if you give birth to a

baby, you go from skyhigh estrogen

levels down to almost nothing when you

deliver your baby and you deliver your

placenta. And so for a lot of women when

they're

postpartum, maybe they've got mood

issues,

um they've got fatigue that is more than

just the sleep

deprivation. This can be a preview of

coming attractions in pmenopause and

menopause. So it's a window of

opportunity that can tell you about the

way estrogen works in your body. So for

the female body, estrogen has hundreds

of jobs. It keeps her joints lubricated.

We know that frozen shoulder is a really

common uh diagnosis in women who are in

pmenopause and menopause because the

estrogen receptors just aren't getting

the estrogen. They're not having

molecular sex between the estrogen and

the estrogen

receptor. So estrogen is really critical

in women. It regulates mood

um breast development, development of

hips. It's a lubricant for your joints.

Um, it's also really critical for your

skin. When estrogen goes down, you make

less collagen and that's why women

notice that their skin ages. And in men,

it's a little bit different. The dynamic

range is more narrow. And what we

generally want with men is for you to

have enough

estrogen to serve some of these bodily

functions like with keeping your bones

strong um but not too much.

Does it have a role in weight

distribution in my body? So where are

the fat stores and stuff? So in men I

don't know. I don't know the answer to

that. I'll have to look it up and get

back to you. But in women, yes,

absolutely. So, one of the things that

happens for women over the age of 40 is

that they typically become insulin

resistant. Their cells become numb to

insulin. And what we know is that they

gain about five pounds of fat and they

lose about 5 pounds of muscle every

decade after age 40. So there's this

redistribution of fat to your point

where they they deposit less at their

breasts in their hips and their buttocks

and more at their

abdomen. Does that happen in

men? I think there's some version of it

in men, but I just would have to confirm

that.

And is that inevitable?

No, no, no. You have a choice.

So for women, I think what's important

is

to

understand what what are your estrogen

levels that are associated with your

best function. And that's why I think

baseline testing can be so helpful to

know where your thyroid is right now,

your cortisol, your testosterone,

um to know where you are with your

metabolic health, so that when you're in

your 40s, you can look back and say,

"Okay, I was in a state of optimization.

I want to go back to something similar

to

that. So for women, what I would say

is right now 73 to 75% of women do not

get the treatment for pmenopause and

menopause that they deserve. They're not

being offered for instance hormone

therapy and that has to change. But

hormone therapy can help to reverse this

so that you are more likely to

um not have some of these body

composition changes as you get

older. And it's not just hormone

therapy. I would say it's beyond hormone

therapy. It's estrogen, progesterone,

testosterone, but it's also heavy

weightlifting. It's cardiovascular

fitness. It's disposing of the glucose

properly. eating the right foods,

disposing of the glucose properly. Yes.

What do you mean by that? So, if you're,

you know, like when I was in my 30s, my

fasting glucose was very high. It was in

the pre-diabetes range. And so, I needed

to change the way that I

was burning through glucose, like using

it with exercise.

So disposing, it's like an input output

equation where you're inputting with

your food and you're outputting with

your exercise and you want to get a good

match between the two and muscle

resistance training, strength training

is the optimal way to dispose of

glucose, right? I think it's a critical

way. I mean, what we know with strength

training is it builds muscle and so the

more muscle mass that you have generally

the better your metabolism.

This one change has transformed how my

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So I showed them to Daniel Lieberman and

he told me that they were exactly the

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And after that I decided to start

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feet. What role is fiber playing in all

of this? Because a lot of people are

talking about fiber at the moment and

saying that we're fiber deficient. Oh,

we are for sure. I mean, the average

American gets somewhere around 14 grams

of fiber a day. And we're meant to have

about 30 to 35 40 grams a day. Our

paleolithic ancestors got even more than

that, 50 to 100 grams a day. So, we are

not getting enough fiber. It's critical

for blood sugar stabilization. So, is

protein intake. But getting fiber from

real

food, you know, eating sufficient

vegetables. We know from the microbiome

studies that you want about 25 to 35

different species of fruits and

vegetables in a week to be able to feed

your microbiome.

And what role is the microbiome playing

in my hormone function? It's playing a

huge role. So your microbiome is one of

the control functions for estrogen

levels and maybe testosterone

levels. So there's a birectional

relationship, Steve,

where there are three bacteria in the

gut that can um take estrogen and make

it keep recirculating.

So, you're meant to produce estrogen and

then use it and then either poop or pee

it out. But what happens with some

people if they've got these bacteria is

they keep recirculating the estrogen

like bad karma. And so those people tend

to have higher estrogen levels. It tends

to be associated in men with this

greater risk of um metabolic

dysfunction, prostate cancer and in

women it's associated with more breast

cancer and endometrial cancer.

And that a lot of that starts and is

caused by the gut microbiome. Yes. And

the microbiome, their favorite food is

fiber. So the way that you keep your

microbiome, your microbes happy and

healthy is to feed them a fair amount of

fiber. What What kind of foods have high

fiber? Is it like broccoli and stuff?

Yes. So broccoli, Brussels sprouts,

cauliflower,

cabbage, kabi.

What do you

eat and like how do you live? So I'm a

sensualist. So I love food. I love the

taste of food. I love the smell of food.

I love the look of food. I had a history

of disordered eating. I had anorexia as

a teenager and bulimia through my 20s

and

30s. But now I have a more neutral

relationship with food. I have worn a

continuous glucose monitor almost

continuously for the past seven years.

And so I know a lot about the foods that

serve me the best. So, usually for

breakfast, I love eggs. And

so, I eat fresh eggs, usually scrambled

or um lightly

boiled. I like to have that with greens

or some other leftover vegetable from

the night

before. I eat a lot of vegetables. I aim

for somewhere around a half pound to a

pound a day. So that's divided between

um salads, the vegetables I have at

dinner, um a smoothie. I put vegetables

in smoothies along with a protein

powder. I eat a lot of cruciferous

vegetables. I have sluggish detox

pathways. I know that genomically and I

know it from my biomarker testing. What

does that mean? Means

that maybe it's related to my

sensitivity. I've got my I don't make

sufficient glutathione, which is um one

of the ways that you detoxify. It's an

antioxidant in your body. And

so

I like to to close that gap by making

sure that I'm getting

sufficient cruciferous vegetables. I eat

a lot of broccoli sprouts. What do you

think of the keto diet? I'm a fan of the

ketogenic diet because in your book

there's this chapter called the keto

paradox. Yes.

What are your thoughts on keto? Well,

what I find with keto is that men tend

to do better on it than women. And what

I found with women is that maybe related

to hormones and their sensitivity, they

have more thyroid dysfunction. They have

more menstrual irregularity. Somewhere

around 45% of women that are on a

classic ketogenic diet. So women tend to

have more issues with the ketogenic diet

takes them longer to get into ketosis

than it does a man. Even if you the

average man if they fast for somewhere

around 14 to 16 hours they start to

produce ketones and for women it takes

longer takes more like 18 to 20 hours.

So probably that's related to fertility

and evolutionarily there's some pressure

for us to not go into a ketogenic state,

but it makes it harder for women to get

into ketosis and stay in ketosis. Is

there a danger to women doing ketosis?

Because you said me um their periods are

going to become irregular. Not

necessarily. I think depending on how

you do it, you know, a lot of the data

that we have on the ketogenic diet is in

populations that don't apply to you or

me because the bulk of the data that we

have is in people with seizure

disorders. So, they're different. It's a

different population and they're also on

a form of the ketogenic diet that is

very strict. You know, no more than 10

to 20 grams of carbohydrates day. So, I

think you can play with your

carbohydrates and find out what your

carb threshold is so that you can remain

in ketosis, get the benefits of all the

phytonutrients that you can get from

vegetables and play both sides so that

you get the health benefits, you get the

metabolic function improvement, you get

the uh lowering of insulin without some

of the side effects. What are the side

effects? The main ones that I see are

the thyroid dysfunction. Yeah.

Uh sometimes there's a a rise in

cortisol in people who are really

limiting their carbohydrates. And then

it can also affect serotonin so that

people don't sleep as well on a

ketogenic diet. Now, some people love

that. They go on a ketogenic diet and

they're like, "Oh, I only need to sleep

six or seven hours a night." But over

time, if you need more and it's the

serotonin that is at the root of why

you're not sleeping as well, that can

cause a problem. Is there anything else

that the keto ketogenic diet might be

doing to my hormones, like my

testosterone or my other hormones that

is worth noting? Because I'm super, you

know, I'm wondering whether to stay on

the ketogenic diet for a long period of

time. I typically do it for a couple of

weeks a year, but I'm I'm wondering if

this is something that I could do for

like a year or maybe longer. So, I think

if you stay on it for more than a few

weeks, you want to check your biomarkers

and you just want to make sure that it

agrees with the intelligence of your

body. So, do some molecular profiling

and see if it's a good fit. Have you

seen people that stay on it for years

and have biomarkers? Yes. Okay.

And I think what's important to

understand is that exercise performance

some sometimes can be adversely affected

by the ketogenic diet. And that might be

an interesting experiment for you to do

like with your running and your 5K time.

What a lot of athletes do is if they

want to experiment with a ketogenic

diet, say they're a cyclist and they're

trying to get their weight down so that

their um power is up, what what they

tend to do before a race is they add

carbs back two weeks before the race so

that they're they're filling their

glycogen stores. And so that that's

another piece that you may want to be

tracking is your exercise performance.

If I'm trying to lose weight, is there

an optimal approach to take? Because the

ketogenic diet has been the fastest way

I've I've ever discovered of losing

weight quickly. But if you're a man or

woman trying to lose weight,

specifically like that annoying weight,

the belly fats, those kinds of things.

If someone comes to you and says that,

what what do you say to them?

What I like about the ketogenic diet for

weight loss, and I'm really careful

about weight loss because it's

problematic. It's problematic. And I

think body shaming is a big problem. And

so I'm really careful about this. But

when it comes to a ketogenic diet, what

I like about it is that ketones are

really satisfying. So they increase your

satiety and I think it's much more

effective than trying to limit your

calories and be in a calorie deficit.

So, with a ketogenic diet, usually you

do a calorie deficit, but you're

producing ketones, which are making you

feel more satisfied, so you're not

standing in front of the refrigerator

wondering when the next time is that you

can eat.

Mhm. And what about

fasting? You know, there's been a lot of

talk about autophagy and doing these

kind of long fasts to heal the body.

What's your perspective on that? I think

there's a time and a place for fasting.

I think these ways of activating some of

the benevolent um pathways in the body

can be very good for you. So it can be

good for mitochondria. It can be good

for uh your hormone balance. It can help

you with insulin as an example. So you

asked about someone who was wanting to

lose weight and also wanting to address

belly fat. I would say that's a

situation where you really want to pay

attention to insulin. So fasting can get

you that. So can a ketogenic diet. Often

we combine the two because you can

induce

ketosis faster by doing intermittent

fasting together with a ketogenic diet.

Is the ketogenic diet like a form of

fasting?

You could think of it that way. I mean I

would I would say it allows you to fast

and it makes the behavior change easier.

[Music]

Um, you know, the thing about fasting is

there are some people who are really

good at it and it doesn't raise their

cortisol. It doesn't induce a stress

response. And then there are other

people who get very stressed with a

ketogenic diet or with fasting. And so

part of it is is trying to get a sense

of your own

response to the food that you're eating

to see, okay, what suits me the best?

How do I feel the best? Where is my

cognitive function at an optimal level?

What helps me with brain fog? What helps

me with allergies or whatever whatever

symptoms you're tracking? You know, one

of the things we know with ketones,

which are produced, you know, your body,

as you well know, is this. It's like a

hybrid car that can flip between burning

gas, which is like glucose in this

analogy, or electric, which in this

analogy is ketones. The thing about

ketones is they're they not they're not

just a satiety molecule that makes you

feel satisfied. They also have

anti-inflammatory aspects inside of the

body. So, they're an important signaling

pathway. There's a reason why your body

produces ketones. Now, do you want to do

that for a

year? We'd have to see. We'd have to

look at your biomarkers. You know, the

the normal way that your genome

developed was to flip in and out of

ketosis based on the food supply. And

now that food is abundant, most people

are not going into ketosis. Been able

but being able to switch back and forth

can be very healthy for you. when people

come to you and they're asking questions

about hormones these days, you must have

seen in your career a shift in interest

um on the subject of hormones, but but

also a certain a certain area of

hormonal health that people have a

greater obsession

with. Of all the sub the subjects we've

talked about today relating to hormones,

what is it that people are most

interested in right now?

I would say for women it's permenopause.

And for anyone that doesn't know what

permenopause is, when does that begin

and what is it? Typically begins between

35 and 45 for women. And it's the age at

which your

ovaries start to run out of ripe eggs.

And the mitochondria in your eggs are

not working the way that they once did.

And so your ovaries are aging and that

leads to changes in your hormone levels.

So a lot of people think of pmenopause

is mostly being a hormonal situation. A

change in estrogen, progesterone, maybe

testosterone. And what I think it's

important to realize is it's much

broader than that. It's your metabolic

system. It's the way that your brain is

responding to glucose. It's your immune

system. It's a time when more women have

the experience of autoimmunity and

autoimmune

disease. So per menopause is this

incredibly dynamic time. There's more

than 100 plus symptoms that women

experience and it makes me crazy. I was

just talking to my agent and my

publisher a couple weeks ago. They're

both women in their early 40s and they

were having symptoms, you know, some of

those hundred symptoms that are uh

characteristic of pmenopause. They went

to their doctor and said, "I've got

these mood swings. I'm having trouble

sleeping. Having some night sweats. Is

this

pmenopause?" And the doctor said, "No,

you're too young." So, there's a

knowledge gap. There's a research gap

and a knowledge gap and a huge treatment

gap for women who are in

pmenopause. Most women are not getting

the treatment that they

need. So, what are they asking about?

out there asking

about why do I feel so disregulated? Why

is it that I can't manage stress the way

I once did? Why would I rather mop the

floor than have sex with my husband? Why

is sex painful all of a sudden? Why do I

have this belly fat that appeared out of

nowhere and my usual techniques for how

to deal with that aren't working? Those

are some of the questions that they ask

which map to your hormones. And what is

the youngest you've ever seen someone

enter permenopause?

Well, I see women who have premature

ovarian

insufficiency, which is when you go

through menopause before age

40. So, I've seen a fair amount of that.

You know,

probably 50 patients over the course of

my career. It's relatively rare. And

then I see women who have early

menopause, which is when they stop

having their periods or they have an FSH

level of 25 to 30. And FA, what's FSH?

Follical stimulating hormone. It's one

of the control hormones for your

estrogen and progesterone in the body.

So if that occurs, they have their final

menstrual period between 40 and 45.

That's considered early menopause.

So there's this really dynamic time

where your hormones are wildly

fluctuating, especially estrogen.

Progesterone is declining and women have

this increase in the symptoms that they

experience and no one is really tracking

it carefully. That's what needs to

change.

tracking it through their blood samples,

blood samples

and connecting their symptoms to what is

happening in their ovaries, in their

immune system, in their metabolic system

and putting it together for them and

offering them options. You believe that

many of the symptoms of menopause are

avoidable? Yes. Yes. And by that I mean

using hormone therapy and using

lifestyle medicine as early as possible

to manage that transition. Because when

a woman goes to a doctor now, that

doctor might say, "Well, you're you're

getting older. This is what happens." Or

they might just completely miss it.

That's

right. Or they might get started on a

birth control pill. That's used a lot

for women who are in menopause. And I

don't think that's the right solution.

What do you think of birth control

pills?

I think if they help you avoid

surgery, they can be beneficial, but I

think they're way overused in our

culture. And most people who agree to a

birth control pill don't receive full

informed consent. They're not told that

it'll raise the inflammation in your

body by two to threefold. It increases

your risk of autoimmune disease,

especially Crohn's disease.

It makes your control system for your

hormones less

flexible. It can rob you of

testosterone. It can lower your free

testosterone. It can shrink your

clitoris by up to 20%. I feel like if

that was part of the informed consent,

very few people would sign up for it.

But who is the birth control pill for

then? You know, I used to think that it

was a feminist invention, that it was a

way

of putting your fertility in your hands.

And I went on the birth control pill

when I was 16. But I feel like there are

some costs to it that um a lot of

teenagers and women in their 20s and 30s

aren't aware of. And for me, I feel like

that awareness is really critical. So,

who's it for? I would say it's a simple

entree into

contraception, but I would much rather

people use things like an IUD or condoms

or some other barrier method that

doesn't mess with their hormonal

intelligence.

How are you doing?

Oh, quite good. Quite good. I love that

question. I went through a divorce two

years ago. And I feel like, you know, I

my I have two daughters. They both went

off to college and were out of the

house. And I realized

that my time with my now

ex-husband had run its course and we

came together to create this beautiful

family, but we were no longer a good fit

for each other. So, a big part of my

spiritual work has been coming to terms

with that and

um and really getting clear about okay

for the second half of my life, what is

it that I

want? What is my mission? How do I

support that? How do I only give a whole

body

yes to um the things that I say yes to?

How do I whole body? Yes. What does that

mean? Whole body. Yes. So, this is

something I learned

from one of my mentors, Diana

Chapman. Um, she learned it from, I

believe, Katie

Hendricks, who's a therapist. The idea

is that instead of saying yes to things

that you're

offered purely from a cognitive place,

that sounds like a good idea. Sounds

like a good opportunity. Let me do it.

Instead, you check up check in with your

whole body. You check in with your

heart. You check in with your your gut.

Does this really make a difference in

the world? Is this something that's

going to make

me jump out of bed in the morning? Is

this something that is worth the time

and the

effort? I'm a little older than you and

so I hold these opportunities a little

bit differently than I did in the past.

How long were you married for? How long

were you in a relationship with your

partner? We were together for about 22

years and married for 20.

How does one know that it's not right

anymore after 20 odd years?

Well, I would love to riff on this with

you. Okay. So I can tell you

that part of the challenge in my

marriage was that

um we had difficulty talking about

difficult topics. So highly charged

topics were tough for us to be able to

navigate. When we had a conflict or a

fight, we didn't repair very well. There

was a partial repair where you would

feel good enough to keep functioning and

take care of the kids and do your

householder stuff, but you didn't really

feel seen or like you cleaned up the

pain that was

there. There was a way

that I didn't feel fully understood or

seen. And not that I require that from

my partner, but I I felt

like there was a

misatunement. And I'm in a relationship

now where I have those things that I'm

talking about. And it's someone that I

have known for 30 plus years. We were

interns together at UCSF.

And I realize now

that, you know, I came together with my

ex-husband and I really am so blessed by

the life that we had and um the family

that we had,

but we also had a trauma bond. There was

a way that his trauma kind of

intersected with my trauma and we hung

in there for a very long

time, probably longer than we should

have.

So, how do you

know? I don't know, Stephen. I just can

tell you

that there was a way

that our

interactions was creating

disregulation in my body. And I'm not

blaming him. I, you know, it's a two

there's two sides of the street. But

there was a way that we just we didn't

quite gel together.

And is that not something that can be

prepared through communication and

therapy or sitting down and I mean you

would hope so, but we spent about 10

years out of the 20 years of marriage in

couples

therapy and it didn't really resolve

some of these conflicts.

We got better at eye statements. We got

better at saying what we were feeling

and not blaming. We got better at

um going for a walk when we were talking

about something

difficult. But there was still a way

that I felt alone and lonely inside of

the

relationship. And I decided I think a

fair number of women decide this. I

decided I was better off alone than to

continue in the marriage. When people

hear that that weren't in your

situation, they might think, okay, so

maybe he was preoccupied with something

else or he was he worked away. When you

say the word lonely, these are the kind

of things we think. We think of

proximity. But you're saying it I'm

guessing it wasn't proximity.

It wasn't proximity. I think it

was there was a way that we had a hard

time expressing love and feeling and

receiving

love. There was an

obstacle and some of it was trauma. And

the good news is there's a lot you can

do to resolve trauma.

But there was a way that

I I got to the point where I couldn't

try any longer. I tried for a lot of

years and I just couldn't keep trying.

When you look back, is there something

that could have been done further

upstream to prevent you getting to this

place in your view? Yeah, it's such a