Welcome to Huberman Lab Essentials,

[music] where we revisit past episodes

for the most potent and actionable

science-based tools for mental health,

physical health, and performance.

I'm Andrew Huberman and I'm a professor

of neurobiology and opthalmology at

Stamford School of Medicine. And now for

my discussion with Dr. Sarah Gotfrieded.

Dr. Gotfrieded. Sarah, welcome.

>> Thank you. So happy to be here.

>> Yeah, I'm delighted and very excited to

ask you about an enormous number of

topics. You are expert in so many

things, female hormones in particular.

Is it ever informative for a woman,

regardless of age, to know something

about her mother's, perhaps even her

grandmother's experience visav hormones?

What sorts of conversations should women

be having with themselves and with

family members to get a window into what

their specific needs might be?

>> So, my work is really at the interface

between genetics and environment. And I

think it's essential that you understand

what your grandmother went through and

especially your mother. So I would

probably start first with trauma and

intergenerational trauma because I think

that affects the endocrine system so

hugely especially cortisol signaling.

And then there's certain female

conditions that have a very strong

component genetically, most of which run

in my family. So that includes

endometriosis, fibroids, and polycystic

ovarian syndrome.

>> Maybe we could march through and just

say for a woman in her teens who's

already hit puberty, what sorts of

biomarkers should those young women be

paying attention to? Likewise for women

in their 20s, 30s, maybe we could take

it more or less by by decade at starting

at puberty.

>> In your teenage years, what I think is

really interesting is to look at

cortisol, to look at the dance between

estrogen and progesterone in those years

is less helpful because I think there's

a lot of variability due to the

immaturity of the system. If you've got

someone who's got really regular

periods, it's probably better to do some

benchmarking at that age. But generally,

I find that benchmarking is best

performed in your 20s or 30s.

>> Are periods not that regular in terms of

duration of the menstrual cycle? When

the menstrual cycle first sets in?

>> For a lot of women, they're not regular.

And then there's the whole piece of oral

contraceptives and other forms of

contraception where you have no idea

what the normal cycle is. But getting

back to your original question, which is

about biomarkers per decade, in your

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

base casing with estrogen, progesterone,

and testosterone. What happens a lot of

the time is that estrogen dominates in

that tango. And when that happens, it

sets you up for greater risk of

fibroids, endometriosis.

I'd want to know about DHEA and sort of

the whole androgen pathway. I'd want to

know about the metabolites of estrogen

because some of them are protective and

very helpful. Others are a bit like

Homer Simpson. I mean, [clears throat]

they are just like causing all kinds of

problems in your body. I'd also like to

know about their stool. So, I want to

know about the microbiome.

>> In terms of blood testing or various

tests for these other biomarkers,

getting estrogen, testosterone, and

other ratios, women will need to do it

at different stages of their menstrual

cycle. if they had to pick one either in

the follicular phase and or in the

ludial stage of their ovulatory

menstrual cycle, when would you suggest

they do that?

>> So, if you forced me to pick one, I

would say probably day 21 to 22 for

someone in her 20s. So, for most women,

they've got a menstrual cycle date that

averages out at 28 days. So, this is

about a week before they start their

period. For women who are more

irregular, it's harder to do that. As

women get older, usually the cycle gets

a little shorter. So, as they start to

decline in their progesterone

production, their period gets a little

closer together. At that point, you want

to test sooner, like day 19, 20. Blood

test is the cheapest thing. It's usually

what's covered by insurance. But my

preference would be to do dried urine so

that I get metabolomics in addition to

the levels of these hormones. And if I'm

forced to, I'll use blood testing. It's

not as comprehensive and as you know

it's a quick little snapshot while the

needle's in your vein for you know 30

seconds. Let me go back and say one

other thing about biomarkers. A big part

of the testing that I do in phenotyping

my patients I practice precision

medicine. I like to almost start with

nutritional testing. That would be

potentially a helpful thing to do in

your 20s. Becomes less important as you

get older and you develop more

micronutrient deficiencies. But

micronutrients play a huge role in terms

of hormone production. Magnesium is

hugely involved in the way that you get

rid of estrogen as an example. So

micronutrient testing, what I usually do

is a combination of blood and urine. And

so I'm looking at all of the

micronutrients that we can measure that

have some clinical scientific basis

behind them. intake of vegetables,

polyphenols, is such an important

predictor of future risk of breast

cancer, like when you're 50, 60 plus.

And the most important time is when

you're a teenager. If you have evidence

that you could show a 17-year-old that

they've got micronutrient gaps, I think

that would be a motivator for them to

eat differently at a time when it's so

critical, even though it's 25 years in

the future, that it's going to

potentially change this arc that they're

on. What do you do for a young woman who

doesn't like vegetables is or is not

somehow able or willing to to get those

five colors a day of vegetable to help

support the microbiome? What other sorts

of tools, behavioral or otherwise, are

useful?

>> What I try to get them to do is to have

a smoothie. If I could get them to have

a smoothie three times a week and to

throw some of these vegetables in, that

makes a huge difference. I mean, we know

that makes a difference in terms of

microbiome change. Like I have them do

steamed broccoli that's in the freezer

because it's got very little taste. They

could do that in a chocolate smoothie.

They could add some greens. I like

greens powders are super convenient. So

that with you know kind of a a taste

that they like whether that's chocolate

which is what most of my clients want or

you know vanilla with berries and that

sort of thing. So that can go a long way

if you don't like vegetables. And short

of that, I would say some supplements,

but I would say that's a distant second

to making a smoothie.

>> What is going to be the best way to test

the microbiome?

>> What I like to do with nutritional

testing is run a panel that's looking at

antioxidants. So like vitamin A, vitamin

C, alpha lipoic acid, plant-based

antioxidants, because you can measure

that in the blood. I like to look at

some of the key vitamins, especially the

B vitamin range, because as you probably

know, if you've got particular genetic

polymorphisms, you might be less likely

to be absorbing the right level of

vitamin B9, folate, vitamin B12, etc.

I'm also looking going back to the

antioxidants at glutathione because I

think that's such an important lever.

And then I'm looking at some of the

minerals. Magnesium is really the most

important and we know that somewhere

around 70 to 80% of Americans are

deficient in magnesium. That's like the

the lowest hanging fruit.

>> I would be curious for instance like

with magnesium if that number of people

are deficient does that mean that that

number of people should be targeting

their nutrition towards foods that

contain magnesium andor supplementing

with magnesium? And if so what forms of

magnesium? You have to measure red blood

cell magnesium like whole blood. And

with deficiency, it's interesting with

supplementation

[snorts and clears throat] for my

patients who tend toward constipation,

and that's frankly about 80% of the

women that I take care of.

>> Really?

>> Yes.

>> Wow. I'd be curious as to why that that

is.

>> Patriarchy,

rage, the pine system,

>> right? psychology, immunology, neural

and endocrine factors combined. Is that

>> Yes. And then I would say there's

another factor. Being female is a health

hazard. So we have twice the rate of

depression, insomnia. We've got 3 to 4x

increased risk of multiple sclerosis.

We've got 5 to eight times the risk of

thyroid dysfunction. So if you just look

at that and you look at subtle

preclinical thyroid dysfunction, a large

number of the women that I take care of

have thyroid dysfunction that's

contributing to constipation. And if we

go back to that control system, the

hypothalamic pituitary, adrenal,

thyroid, canatal, gut axis, and they

have a lot of perceived stress together

with this borderline thyroid function

that no mainstream medicine doctor has

told her is a problem. And then she's

got a problem with the tango between

estrogen and progesterone. She's going

to tend toward constipation. Women have

a lot more constipation than men.

[clears throat]

The gut is about 10 ft longer in women

compared to men. And they are much more

likely to have a torturous colon. And

the way you know that is you get a

colonoscopy. Women experience more

trauma than men. [clears throat] This is

well established. If you look at the ACE

studies that were done by the CDC and

Kaiser in 1998, we know that men for the

most part, middle-aged men have about

about 50% of them experience significant

trauma as defined by the ACE

questionnaire. Women are at 60%. And

that's pretty durable since 1998. They

have different forms of abuse, much more

likely to have sexual abuse. They have a

different HPA response than men.

their perceived stress tends to be

higher. And I'm generalizing for a

population. And so if you look at the

physiology of a female, I think that um

constipation and that need to like

control and restrain and hold things in,

I think that's part of the physiology.

So I'm veering away from the science,

but I do think that it is a really

important signal to pay a lot of

attention to. What sorts of tools do you

recommend people use to relieve

constipation? Sounds like reducing

stress is going to be a huge one.

>> Yes.

>> What are your favorite stress reduction

tools? Things that can really lower the

baseline.

>> So, I'm not a fan of lowering stress.

I'm a fan of lowering perceived stress.

I think all of us need an allocart menu

of what is most effective.

So what works for me now at my age is

different than the TM I did as a college

student transcendental meditation. I

became a certified yoga teacher when I

was in my 30s. That is very effective

for a lot of people. I do holotropic

breath work.

>> I think people are starting to

appreciate that there are ways that they

can relieve their stress that that don't

all only fall under the categories of

vacation,

>> right,

>> and meditation. But I want to say that

meditation is obviously a wonderful

tool. Well, certainly it's a great tool

and it's got such a scientific basis

behind it, but there's so many things on

this allocart menu. Sex, orgasm,

um, connection, feeling heard and seen

and loved. I want to use this as an

opportunity to a keep this in mind as a

return to a a question that I didn't uh

close the hatch on earlier and it's my

fault which is I'm now clear on the fact

that a woman in her late teens early 20s

ought to know something about her

testosterone estrogen thyroid cortisol

levels should start at least thinking

about her microbiome

should be thinking about how many bowel

movements and the timing of those bowel

movements per day and I'm assuming that

what I just described is also true for

women in their 20s, 30s, 40s, 50s on up

to hundreds. Is that correct?

>> That's correct. But I would say that

there are differential opportunities by

decade. So, I'm glad you circled it back

to teenagers and testosterone because I

think if you know, for instance, in your

teenage years that you have high

androgens and that you've got this

potential phenotype way into the future

that you may not even notice. I mean,

maybe you notice you got a few extra

hairs on your chin or something. If you

know that your testosterone is elevated

or some other androgen, it might change

the arc of how you take care of

yourself. So I think that could be very

helpful in your teenage years. In your

20s for people who are a stress case

like me, so age 27 on the wards at UCSF,

if I had known that I was such a high

cortisol person, I think I would have

done things differently. I would have

changed my behavior. Your testosterone

[clears throat] can decline starting in

your 20s, kind of depending on how much

stress your matrix is under. So for

women, that can start as early as 28.

Usually your testosterone declines by

about 1% per year.

>> What level of testosterone do you like

to see in a woman once she's sort of

post let's say after age 25.

>> So the way I tend to describe this on

podcasts is the top half of the normal

range.

>> I get a lot of questions about PCOS.

>> Yeah. So PCOS is one of those really

poorly understood conditions. It kind of

flies below the radar until a woman

wants to get pregnant or she's got some

other issue that drives her to a

physician. The problem is that it is a

syndrome, right? So, polycystic ovary

syndrome, sometimes polycystic ovarian

syndrome and syndromes don't necessarily

fit together into a really clear

diagnostic criteria. So, in this

instance, there are three different

criteria that we look for. cysts on the

ovaries having clinical manifestations

of hyper androgenism. So that could be

hercetism, acne, other things and then

usually irregular periods and the way

that that's defined at least by the

latest criteria is having a period every

35 days or less. So typical cycle length

28 days, 35 days, you know, you're

skipping a period here and there. So

those are the criteria that we use to

diagnose PCOS. There are about four

different systems out there in the

literature for diagnosing PCOS, which is

where it starts to get confusing. So

there's some women who have no cyst on

their ovaries, but they've got heretism

and they've got irregular periods.

>> Could you define heretism?

>> Here is increased hair growth, usually

in places that you don't want it. So for

women, it can be, you know, kind of male

pattern. They might notice it on their

breasts, on their chest. What we know is

that PCOS is not just a problem in terms

of irregular periods and then difficulty

getting pregnant. So those are mostly

problems in your 20s, 30s, early 40s.

But it is a massive risk factor for

cardioabolic disease as you get older.

So many people tend to pigeonhole PCOS

as a problem of reproductive age. We

have to be thinking of it over the

entire female life cycle. And I would

say it's even more important to consider

it over the age of 50. You know, average

age of menopause is 51 to 52 because we

know that that elevated testosterone,

the high androgens

are probably the greatest card metabolic

driver of disease for women with PCOS.

The thread we haven't talked about is

the role of insulin and glucose.

So for some of the phenotypes of PCOS,

the problem is hyperinsulinemia,

high insulin in the blood is driving

those theta cells in the ovaries to

overproduce testosterone.

>> Are you a fan of continuous glucose

monitors?

>> The hugest, most gigantic fan of CGMs.

I've never seen any tool that I've ever

used in medicine change behavior the way

that CGMs do. Like I think really

understanding what the mediators are of

your glucose control is essential. Now

that said, it's also kind of a later

effect. I mean, I'd rather know your

insulin and we know from uh the

Whitehead White Hall study that insulin,

especially postprandial insulin, fasting

insulin too, can change years and years

before you get a change in glucose. So,

um that's more for pre-diabetes and

diabetes. Third thing is it democratizes

data. One of the most hopeful and

exciting things that I'm seeing right

now in the health space is that we're

going from this patriarchal relationship

where doctors hold the power and are the

gatekeepers of data to patients and

clients having much more access to that

enchantment about their own chemistry

and their own biology. teaching the

patient to be their own clinician. To

me, that is a loop of benevolence and

integrity that I think is essential to

creating health. We've got a disease

care system. We need the democratization

of data to become a health-based system.

If you had a magic wand and you could

give like two or three don'ts to

maximize vitality and longevity. Let's

focus first on female patients, but if

it extends to male patients as well,

what would you like to see them not do?

>> So, I would say sleep, alcohol, high

perceived stress, eating the wrong

foods, toxic relationships, and

isolation. And [clears throat] then

number six, not moving enough or not

moving and exercising in a way that

really fits with your body.

>> Can we start with that one actually just

cuz it's such a and then work backwards?

>> Yeah. Well, I think for me, because I

have a phenotype that produces a lot of

insulin, kind of depending on how I'm on

my game, I have a lot of glucose. So, I

have to exercise a lot more to dispose

that glucose. So, I think you then have

to move from medicine for the population

or prescriptions for the population to

what works for the individual. One of

the mediators that I think is important,

especially for people who do what I call

chronic cardio, which is what I did,

is cortisol. So, we know that runners,

especially marathon runners, people who

do a lot of cardio and don't do much

resistance training, they tend to have

much high cortisol levels. And you can

buffer that with vitamin C. Vitamin C

can decrease the effect. But chronic

cardio doesn't always serve people. When

I first started measuring hormone panels

in myself, I went to my physician and I

said, "I'm 35. I've never been so

exhausted in my life. I just feel like

I'm pushing a rock up the hill. I've got

this belly fat that I don't like and I

don't want to have sex with my husband.

What can we do about this?" And he

offered a birth control pill and an

anti-depressant.

>> Oh, goodness. So, I left him and I went

to the lab and I ran a hormone panel and

my cortisol was three times what it

should have been. [clears throat] My

insulin was in the 20s. I was fasting.

My glucose was 105. My thyroid was

mildly abnormal. My progesterone was

low. And that set me on this course of

realizing that what I was doing as a

physician, taking care especially of

women, was not getting to some of these

root causes that are so essential. And I

would say I had to start first with

cortisol.

At that time, I was running four miles

three times a week, four times a week.

That was just raising my cortisol

further. So that was not the right

exercise for me. I needed more adaptive

exercise. I started doing Pilates, more

yoga. That helped to lower my cortisol.

I mean, it started me on changing the

way I was managing perceived stress and

it also changed my supplement regimen.

>> I'd like to make sure that we circle

back to birth control in particular oral

contraceptive birth control. What are

your concerns? What do you like about

oral contraceptives? What do you dislike

about them?

>> In terms of benefit, I think that

especially when they first came out and

even now, it gives women reproductive

choice and that's essential. So I'm a

big fan in that regard and we've got a

lot of data to show both the risks and

also the benefits of it. So I'll speak

first into the benefits because I'm

going to get on a soap box a little bit

about the risks. So we know that it

reduces the risk of ovarian cancer. So

there's something about this idea of

incessant ovulation that is not good for

the female body. So if you look at for

instance women who are nuns who don't

take oral contraceptives and they have a

period every single month of their

reproductive lives, they have a greater

risk of ovarian cancer. [snorts] So if

you look then at women who have several

babies and they've got a period of time

when they're pregnant that they're not

ovulating and then they breastfeed for

some period of time, they have a lower

risk of ovarian cancer. So oral contra

contraceptives help with reducing

ovulation and reducing risk. We know

that if you take the oral contraceptive

for about 5 years, it reduced your risk

of ovarian cancer by 50%. And that's

significant because

we're so poor at diagnosing ovarian

cancer early. There's really no method

that's really effective. We use CA125

and ultrasound screening, especially in

women who are at greater genetic risk.

But even that often we diagnose it you

know in a later stage.

>> Maybe just because that statement is

going to highlight for a number of

people um the question of what are some

of the earliest symptoms that people can

recognize without a blood test. So is o

ovarian cancer is it going to be pain?

>> So the problem is the symptoms are so

vague and they're so non-specific.

One of the most common symptoms is

bloating. And we've already talked about

constipation. We've talked about how

women have this longer track, GI track,

and so bloating is a really common

experience for most women.

[clears throat] You can have bulk

symptoms, you know, feeling like your

your lower belly is kind of pressed out.

The way that we inform women in terms of

watching for this is to get regular

gynecologic exams for women who are at

high risk where they have, for instance,

an ultrasound for some reason and it

shows a mass that we're concerned about.

there's a way to triage that in terms of

what kind of evaluation that they need

and that's a situation where you might

get a blood test called the CA125.

>> Taking estrogen and thereby reducing the

frequency of ovulation

lowers the risk of ovarian cancer.

Should women that are even women who are

not sexually active, so they're they're

not actively trying to get pregnant or

avoid getting pregnant, but if they're

not sexually active, would they be wise

to suppress ovulation for periodically

using hormone-based contraception just

so that they can offset the risk of

ovarian cancer? That's a very rational

question and I would say that's what

mainstream medicine has had at its back

to recommend oral contraceptives not

just for women who are seeking

contraception but for acne for painful

periods for really kind of the drop of a

hat. They're prescribing oral

contraceptives. That's what I was taught

to do. And I think a lot of that is

pharmaceutical influence. The oral

contraceptive is two hormones. It's

ethanol estradile and [clears throat]

it's a progesterine. So it's not the

normal uh progesterone that your body

makes that your ovaries make and your

adrenals make. It is a synthetic form of

progesterone and it is the same

progesterine similar same class that was

shown to be dangerous and provocative in

the women's health initiative. So I'm

not a fan of progesterines.

I do not recommend them for any woman

unless it it gives them some freedom in

some way. So like with almost any

pharmaceutical, the oral contraceptive

depletes certain micronutrients,

magnesium, there's certain vitamin B's

that are depleted. It also affects the

microbiome. That data is not as strong,

but there seems to be some effect. And

there's also an increased risk of

inflammatory bowel disease and

autoimmune condition. It increases

inflammatory tone. So the studies that

I've seen increase one of the markers of

inflammatory tone high sensitivity CRP

by about two to 3x. It seems to make the

hypothalamic pituitary adrenal axis more

rigid so that you can't kind of roll

with the punches and wax and wayne in

terms of cortisol production the way

that you can off the birth control pill.

It can affect thyroid function. Anytime

you take oral estrogen, it raises sex

hormone binding gabbulin. And you've

talked to other podcast guests about

this, Kyle. I think

>> sex hormone binding globulin I think of

as a sponge that soaks up free estrogen

and free testosterone. So when you go on

the birth control pill, you raise your

sex hormone binding globulin. It soaks

up especially free testosterone.

And for some women, it's not a big deal.

they don't notice much of a difference.

But then there's a phenotype maybe

related to CAG repeats on the androgen

receptor who are exquisitly sensitive to

that decline in free testosterone. So

this then opens the portal of talking a

little bit about testosterone in women.

It's the most abundant biologically the

most abundant hormone in the female

system. It is so important for women. It

is essential to so many things, not just

sex drive and muscle mass and seeing a

response to resistance training, but

also confidence and agency. And so those

women who are so sensitive to their

testosterone level, they've got this

high sex hormone binding gabbulin, their

testosterone declines.

What they describe is vaginal dryness,

maybe a decline in sex drive. But

there's also this bigger issue related

to confidence and agency, even

risk-taking from studies that we've done

with MBA students that I think is a

serious problem.

Maybe the most important out of all of

these things, is that it can shrink the

clitoris by up to 20%. 20%. And if I've

got a woman that I think should not be

on the birth control pill, maybe she's

taking it for acne or she's taking it

cuz her periods were a little painful.

What I'm going to do is say, let's

leverage these other ways of making your

period less painful. Let's take the

message of your painful periods and

figure out, okay, is it your

inflammatory tone and we give you some

fish oil and SPMs, maybe a little

aspirin when you've got your period?

like let's find some other ways to deal

with it than to take the oral

contraceptive which you have not

received informed consent about because

it can trick your by up to 20%. Now

that usually convinces most people to

come. The data that we have is limited.

There's one woman who uh Claudia

something something who looked at sex

hormone binding globulin a year out from

stopping the birth control pill and it

was still elevated. It wasn't as high as

it was when they were on the pill, but

it was still elevated. So, your question

about reversibility, I don't know if we

know the answer to that.

>> What are your thoughts on menopause?

When should people start thinking about

it? And I'm guessing based on everything

you've told me today that there are

women in their 30s that while they may

be 20 years out from menopause, probably

should be doing things now in

anticipation of that. The more you know

about your phenotype, your hormonal

phenotype when you're in your 30s,

you're set up in terms of what to do in

the future, especially things like your

thyroid, your estrogen and progesterone

levels cuz you can replace to a state of

you thyroid. I don't usually go exactly

back to where the estrogen and

progesterone levels were were, but we

can get pretty close. So, in your 30s,

having a base case, I think, is really

essential. What's more interesting is to

talk about pmenopause.

So pmenopause is the the period of time

before your final menstrual cycle. And

for most women, depending on how attuned

you are to the symptoms, it can last for

10 years. So I'm still in period

menopause. It's been like 20 years

because I've been tracking it so

carefully. It usually gets kicked off by

having your cycle get closer together.

So that can happen in your 30s or your

40s. you go from 28 days to 25 days,

that sort of thing. You may notice it as

more anxiety, difficulty sleeping, and

that probably is related to the estrogen

receptor. So, there's this whole period

of permenopause. And what's most

fascinating to me is that there is this

massive, massive change that happens in

the female brain that people are not

talking about enough. And so looking at

the work of Lisa Mosonei at Cornell,

starting around age 40, there is this

massive change in cerebral metabolism.

So you can do FDG PET scans, you can

look at glucose uptake, and there's

about on average a 20% decline from

premenopause up to like age 35 to

pmenopause to postmenopause.

The women who are having the most

symptoms in pmenopause and menopause,

the hot flashes, the night sweats, the

difficulty sleeping, those are the ones

who have the most significant cerebral

hypom metabolism.

>> So, it's almost like a um I don't I

don't want to scare people with this

language, but it's it's a low-level or

let's call it pseudo dementia of sorts.

Yes, it it seems to be a phenotype that

you can then map to Alzheimer's disease

because that's Lisa Muscone's work.

She's looking at, okay, Alzheimer's

disease is not a disease of old age. It

is disease of middle age. What are some

of the biomarkers that we can define

that can tell you what your risk is?

I've got a mother and a grandmother with

Alzheimer's disease. You can believe I

am all over this data.

>> And insulin resistance, insulin

sensitivity, as we talked about before.

um seems to be somewhere in there which

I think when that first when that idea

first surfaced a few people are like

really but then of course right I mean

the brain is this incredibly

metabolically demanding organ you

deprive neurons of fuel sources they or

you make them less sensitive to fuel

sources they start dying they they

certainly start firing less it makes

perfect sense and I think now it's

thanks to Lisa's work work that you've

you've done and have talked about quite

a lot is um in your books and elsewhere

I think has really you

highlighted for people that metabolism

and metabolomics is going to be as

important as genes and genomics when it

comes to that's right

>> dementia

>> perhaps especially in women is it safe

to say that

>> I think so because we believe that this

system is regulated by estrogen

so the decline in estrogen starting

around age 40 43 is kind of the average

seems to be the driver behind cerebral

hypom metabolism the I describe it to my

patients is it's like slow brain energy.

So you walk into a room, you can't

remember why. Like you just notice that

you can't manage all the tasks the way

that you once could. Like things are

just a little slower. And I say that to

women and they're like, I have

[laughter] that like help me. We've got

all of these women that are marching

toward potentially a greater risk of

Alzheimer's disease. And they have this

opportunity in their 40s and their 50s

to take hormone therapy. and they may

not be offered it because the typical

conventional approach based on whi is to

say unless you're having hot flashes and

night sweats that are severe, I'm not

going to give you hormone therapy. And I

I just want to call that out. I would

say no, that is not the way to approach

it. The concept right now in

conventional medicine is that hot

flashes and night sweats are these

nuisance symptoms that we will take care

of temporarily. Doesn't matter that

you're not sleeping anymore. Turn down

the temperature in your room. And that's

not right because hot flashes and night

sweats are a biomarker

of cardioabolic disease. They are a

biomarker of increased bone loss. They

are a biomarker of changes in the brain.

So many of these symptoms that occur in

pmenopause are not driven by the

ovaries. They are driven by the brain.

>> I just want to say you've taught me a

tremendous amount. the amount of

knowledge that you shared is is immense

and is going to be very useful and

actionable for women in particular.

>> Can I just add one last thing because I

didn't talk about it since we didn't get

to the 40s and the 50s in this list of

biomarkers.

>> Please do.

>> If women went away with one thing today,

>> it would be to do a coronary artery

calcium score

>> by age 45 and sooner if you've got

premature heart disease.

>> How is that taken? So, it's a CT scan of

the chest. You can self-order it. It

almost gives you this fork in the road

in terms of how much you need to pay

attention to cardio metabolic health as

a woman. It's so fascinating because,

you know, there's some women who have a

zero. So, my score is zero. But if

you're 45 and you're starting to be

elevated or you've got, you know, maybe

you've got PCOS or you've got some other

biomarkers tending you in this direction

toward the number one killer that allows

you to really start to make changes. And

I I think it's essential to know that

data. Most conventional doctors are not

going to do it.

>> So if I were to go to my doctor and I

just say I want a a cardiac calcium

score. That's what people

>> coronary artery calcium score.

>> Okay. There are certain people they are

exceedingly rare but you are one such

person that when they speak knowledge

just comes out of them and it's

incredibly useful and helpful knowledge.

So

>> thank [music] you.

>> Thank you.

>> [music]