Dhru Purohit Show - Why It’s So Hard to Lose Weight for Women 40+ and How to Optimize Hormones During Perimenopause and Menopause with Dr. Sara Gottfried

Episode Date: November 16, 2023

As women approach their mid to late thirties, they often suffer symptoms that are ignored or dismissed by conventional medicine. Insomnia, weight gain, irritability, reduced memory, and brain fog are all symptoms that can drastically change the quality of life for women. Today’s guest is here to show us that there is hope and that it doesn’t have to be this way.  Today on The Dhru Purohit Podcast, Dhru sits down with Dr. Sara Gottfried for a deep dive into women’s health, specifically the changes that occur in perimenopause and menopause. Dr. Gottfried shares the symptoms women in these categories face and the science behind why they occur. She shows us the critical tests that need to be addressed, offers practical tips women can implement to address these changes and balance key hormones, and inspires women to empower themselves on their road to longevity. Dr. Sara Gottfried is a board-certified physician who graduated from Harvard and MIT. She practices evidence-based integrative, precision, and Functional Medicine. She is a Clinical Assistant Professor in the Department of Integrative Medicine and Nutritional Sciences at Thomas Jefferson University and Director of Precision Medicine at the Marcus Institute of Integrative Health. Her three New York Times bestselling books include The Hormone Cure, The Hormone Reset Diet, and Younger. Her latest book is Women, Food, and Hormones. In this episode, Dhru and Dr. Gottfried dive into (audio version / Apple Subscriber version): The metabolic crisis that women in their 40s go through (2:30 / 2:30) How conventional medicine often dismisses these symptoms 10:18 / 7:37)  The top misconceptions or misunderstandings about the interplay between hormones (16:12 / 12:46) Common symptoms of perimenopause and menopause as they relate to aging (22:05 / 18:30) The environmental and lifestyle factors that impact women’s hormones (31:40 / 26:20)  The top 3 hormones to balance and correct: cortisol, estrogen, and thyroid (41:38 / 36:10) How Dr. Gottfried started her hormonal journey by testing her cortisol (51:10 / 47:00)  Dealing with insomnia during perimenopause (1:03:20 / 57:54) Testing thyroid levels and the connection between thyroid and autoimmune disease (1:16:00 / 1:11:12) Bringing hormones in harmony (1:22:00 / 1:17:02) The key to feeling better by addressing glucose levels (1:33:00 / 1:28:10) The role of post-traumatic stress and the use of psychedelics (1:54:15 / 1:49:45) Dr. Gottfried’s message of how it doesn’t have to be this way (2:12:30 / 2:07:40) Also mentioned in this episode:  The Charlie’s Angels of Hormones graphic Levels This episode is brought to you by JOOVV, LMNT, and Armra Colostrum.  Right now, Joovv is offering an exclusive offer on your first order. Head over to Joovv.com/dhru and apply my code DHRU. Right now, LMNT is offering my listeners a free sample pack with any purchase. Head over to DrinkLMNT.com/dhru today. Receive 15% off your first order of Armra Colostrum at tryarmra.com/DHRU, or enter DHRU to get 15% off your first order. Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit megaphone.fm/adchoices

There was a study done at the University of Texas in San Antonio that showed that women who have a high cortisol level in the morning in their 40s. So in mean age of 48, those women with a high cortisol level shrunk their brains. They had a decrease in their total brain volume and they also had a change in their memory. If you're ready to deep dive into a master class on all things women's health, especially for women that are in the perimenopause and menopause. stage of their life, today's episode is absolutely for you. Welcome to the Drew Proet podcast. Each week we explore the inner workings of the brain and the body with one of the brightest minds in wellness, medicine, and mindset. This week's guest is Dr. Sarah Godfrey. Dr. Sarah Godfrey is a physician,

researcher, educator, mother, and seeker. And she's here with us today on the podcast to talk about the top drivers of abnormal hormonal health. That's causing so much suffering, especially for women in the 40, 50-plus age demographic, and most importantly, what women can do to address these abnormal drivers and feel better today. Now, a little bit more about Dr. Sarah Gottfried. Dr. Godfrey is a graduate from Harvard Medical School and MIT and completed her residency at UCSF. In addition to being a medical doctor, she's also a global keynote speaker and the author of four New York Times best-selling books about trauma, hormones, and health. Currently, she's a clinical assistant professor in the Department of Integrative Medicine

and Nutritional Sciences at Thomas Jefferson University and the director of precision medicine at the Marcus Institute of Integrative Health. Dr. Godfrey's focus is at the interface of mental and physical health, end of one trial design, personalized molecular profiling, the use of wearables, and how to leverage these tools to improve health outcomes for everyone, but especially women. You've shared that after the age of 40, going into our 50s and beyond, there's this metabolic crisis that most women will go through. You yourself have stated that when you were in this period of your life, you just couldn't lose weight right around that time. So many women that tune into this podcast and are consuming this health information, they're asking, what the heck is going on with my body and what?

Why is it so much bigger for them than just gaining a little bit of extra weight in our bellies and other parts of our bodies that we typically didn't use to? There's a number of events that conspire against us after 40. I think the biggest one is the change in estrogen and progesterone. So as estrogen starts to decline, you get this redistribution of your weight. So it used to be before you went through menopause, like through, through your 20s and 30s, that as a woman, you deposit fat at your breasts, at your hips, at your buttocks.

After 40, as estrogen starts to wildly fluctuate and then go down, you don't distribute it there anymore. You distribute it at your waist. So along with that, you also gain about five pounds of fat and you'll lose about five pounds of muscle every decade unless you're doing something about it. So that's one change. Another change is you become more insulin resistant. So glucose is start to go up. And this is really the metabolic health crisis that's going on. It's related to how mitochondria are functioning. Some women notice it in terms of not being able to zip up their pants, that sort of insulin resistance where you store fat no matter what. Other women notice it more in their brain. They've got more brain fog. They've got what Lisa Mosconi calls serenial. hyperal hypometabolism. You just don't use glucose the way that you once did. There's also a cortisol problem. You get more stressed. You may find that you fly off the handle more easily. Cortisol tends to

rise as you get older. Not for everyone. There's some people who get a burnout state with cortisol and it can become low, can even be high or low within the same day. But that tends to also drive blood sugar. And then the fourth issue is your thyroid. So thyroid tends to to become less functional as you get older. And most of the people who are affected by thyroid dysfunction are women. Do you feel that for those that are listening in today, if they stick around for this conversation and get a chance to hear all your incredible expertise that you have on this topic, that there's a different way of being,

that this common way that many people, not just women, right, just going broader in the population, are aging in a way that makes people almost, afraid to age sometimes, that there's, it doesn't have to be that way. That's the crux of this conversation, Drew, because it doesn't have to be that way. So I think a lot of us look at the aging process, especially after 40, as this burden, you know, all these hormones that are changing. Do we want to take hormone therapy, bioidentical hormone therapy? Yes, no.

Do we want to be working with our hormones in a different way? And I think the problem is conventional medicine just isn't set up to solve this for us. And I know because when I was struggling in my late 30s, I can still remember being 39, going to my primary care doctor and saying, I can't lose the baby weight. I had my second baby at 38. I feel stressed all the time. I've got premenstrual syndrome that's on steroids. It's way worse than it ever was.

What do you have to help me? and I was offered a birth control pill. I was offered an antidepressant, a selective serotonin re-uptake inhibitor. And he told me to exercise more and eat less. And that was the moment where I just realized, okay, if I'm not being served well by the advice from conventional medicine, then there are millions of women who are also not being served well. And so that was my moment where I just, I stood up and said, okay, we got to do this. differently. We've got to find a different path that allows us to navigate these hormonal changes

and to do it with grace and to do it in a way that is natural and healthy, doesn't cause any long-term problems, and really allows us to serve our purpose here on the planet, not just kind of disappear and melt away and become more fat as we get older. This episode is brought to you by Jouve. One of the easiest ways to boost cellular health naturally is red light therapy. Juve has been my go-to device for harnessing the power of red light therapy for years. Let me tell you why I love it. With over a thousand scientific studies supporting its effectiveness, red light therapy has been shown to help strengthen the mitochondria, reduce pain and inflammation, increased circulation, enhanced performance, muscle recovery,

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This deal is only available through my link, so you've got to make sure you go to drink element.com slash D-H-R-U. You know, you made a video recently on YouTube and you shared it beautifully there.

You said that you regularly hear from patients that they go to their doctors. Obviously, this is before, or becoming a patient with you, with symptoms of perimenopause, like, I'm gaining weight. I can't sleep. I'm more moody. I don't have energy like I used to.

I'm so hot all the time. I have night sweats. I've lost my sex drive. And they take these to their doctor. And often their doctor is not super helpful. In fact, many women, including like yourself, feel that they were dismissed. let's zoom out a little bit big picture. And we're going to come back to weight gain and some of the strategies and tips that

you've implemented in your own life and that you teach your patients. But let's zoom out big picture. What did you learn as a medical doctor about these combinations of these symptoms, especially as women are gearing up for perimenopause? Well, the conventional approach that I learned is that there's this laundry list of symptoms. that women start to experience. And it kind of depends on how sensitive you are, whether you notice more or less of them. And those can start as early as 35. It can start with your period getting a little closer together. And that's a progesterone effect, as you make less progesterone and you run out

of ripe eggs. The other thing that I learned is that the conventional approach is really to give a birth control pill, and not usually to offer bioidentical hormone therapy. So I was really taught to tell women, this is just part of the aging process, get used to it. But I found that totally unsatisfying. And when I was there myself and struggling with a lot of these symptoms, I realized there's got to be a better way. There's got to be science behind a better approach that allows us to navigate all of these hormonal changes and to do it in a way that really allows us to live our best lives in middle age. So that's what I said about doing. And I think what you're asking is, what did I learn when I kind of took that right turn when I turned away from conventional medicine and said,

okay, I've got this low progesterone. My periods are getting closer together. What can I do about it? oh, there's this herb called Chaseberry for a randomized trials. Show that it helps with PMS. It helps to raise your progesterone levels. It helps to kind of nudge your ovary to make more progesterone when you're in that early perimenopausal phase. So that's just one example of some of the things that I learned when I took to the science to be able to answer some of these questions. So I think that's what we have to do because if we zoom out a little bit, part of the problem here is that

women were part of a vast, uncontrolled medical experiment for about 59 years as they were going through parimenopause and menopause. So they were given synthetic estrogen and progesterone, Premarin and Provera without a randomized trial to show that it was safe and effective. And so many women were taking these hormones. In fact, Premarin was the number one prescribed medication in the United States for decades. So we finally had a randomized trial that was published in 2003 that showed that it was potentially dangerous and risky. And then millions of women came off of their hormones and they weren't offered really any

alternative. So we have to find the middle path here. What's science-based and what can be the most effective to help us with these symptoms? And I also learned there's more than a hundred symptoms that you can experience through perimenopause and menopause. It's not just, you know, a few that I learned when I went through my OBGYN training. So we need to be tuning into this bigger picture. And then if I put my hat on as a precision medicine doctor, what we now know, know is that there are these dramatic, vast changes that occur not just in your hormones, but the entire matrix of your body. Your immune system, your metabolic system, your neurological system, and your hormones are all changing in concert. And we want to be aware of all of those

changes so that we're not just focused on, okay, what's your estrogen level? What's your progesterone level? We want to be thinking, okay, what's happening with glucose metabolism? What about upstream with insulin? How is estrogen talking to your insulin? How much stress do you have? Are you someone who's experienced trauma? And you've got a dysregulated response with cortisol. And we need to address that. We need to clear the trauma. So we want to be thinking about all these threads that lead to a woman who's going through this change. Typically, sometime around 35 to 45, this change into perimenopause. and needs our help, you know, needs a way to navigate it and not just be told, oh, you're getting older, get used to it. So that's dismissal. And then it can even become more like gaslighting of,

well, that's not what I see in my other patients. And I don't think that's related to perimenopause or menopause or I don't think we need to check your levels because they fluctuate so much. it's not worth it to measure it. So there's lots of behaviors that happen, I think, in conventional medicine. I'm not blaming them. I'm just saying this is the way that we're trained, and it's not serving these women. You know, you talked about the concert of hormones that are there and the interplay between them. What do you feel are the top misconceptions that people have about this interplay?

Misconceptions, okay. Misconceptions or even misunderstands. or even misunderstandings. There's a lot of them. So I'll start with the one I had when I was in my 30s. So I thought menopause was this cliff that I would fall off of, you know, sometime around 50 or 51. And that I really didn't need to worry about my hormones until then.

And that's just not true. Because if you look under the hood, there are these subtle changes that can happen 10 to 20 years before your final menstrual period. And so just to define some of these terms, Please. Menopause is when you have a year from your final menstrual period. And that can be somewhat confusing because a lot of people kind of use menopause as a broader term.

But menopause is really one day. It's a one day anniversary. Or if you're someone who's had a hysterectomy like I have, then it's when your control hormone for your estrogen, your follicle stimulating hormone or FSAH is above a certain level, usually 25 to 35. So we've got this definition for menopause, meaning of 51 to 52 in the United States. But then there's this 10 to 20 years beforehand that can be, you know, really kind of a wild ride some of the time in terms of perimenopause. And with perimenopause, I even like to divide that a little bit further if you're still with me here. So the first half of perimenopause is when estrogen fluctuates wildly. And we can see it all over the place. Like if you measure estrogen, it can really fluctuate day to day.

And then the second half of perimenopause is when estrogen starts to decline. And then that leads up to your final menstrual period. So perimenopause can go on for quite a while. So I started around 35. And I'm now 56. And I am still in perimenopause. So depending on how attuned you are to it, it can go on for a very long time. So that's the first misconception that, you know, menopause is this future thing that's going to happen to you. You don't have to worry about it until you're 50. I want people to be thinking about it much sooner and preparing for it because this is where lifestyle becomes so important. The way that you eat, move, think, your sense of purpose and meaning, your connections, all of those map to your experience of perimenopause. So that's misconception number one.

Misconception number two, I would say, is that you're just getting older and you're kind of stuck with all these things that are happening, that you have no agency, you have no control over it. Totally disagree with that. So I've spent the past 15, 20 years really trying to teach people, taking them by the hand and teaching them how to navigate these, you know, sometimes rocky, roiling hormones hormone experiences that they're going through. And there are so many ways that you can kind of gently guide your hormones in a particular direction. You know, if we take cortisol as an example,

cortisol is the main stress hormone. And some folks just think, oh, my cortisol's high, I'm stuck with that, or my cortisol's low, I've got maybe post-traumatic stress disorder, I'm stuck with that. But you can actually change your cortisol on an hour by hour basis. And I really encourage people to come up with an all-a-cart menu of all of the ways that they most like to manage their cortisol. And I even like to think of cortisol as being kind of like your retirement account because, you know, a lot of folks think that the money they have in their 401k and their IRA is the most important thing in terms of retirement. I would say cortisol is the most important because here's why.

There was a study done at the University of Texas in San Antonio that showed that women who have a high cortisol level in the morning. They measured it in the saliva. In their 40s, so mean age of 48, those women with a high cortisol level shrunk their brains. They had a decrease in their total brainfirm. volume and they also had to change in their memory. And we're not talking about women who are 65, 70, 75. These are women with the mean age of 48. Wow. High cortisol, decreased brain volume, decreased memory. And so we want to be thinking about this. I'm not trying to scare people. I'm

just trying to motivate you to realize that you can start to change this. So, you know, what do you do to change it? Meditation. For me, it became non-negotiable to be a lot of a meditator starting in my 30s. I mean, I learned transcendental meditation when I was in college. I've practiced yoga all of my life. I love yoga as a form of managing cortisol. And we all have our favorite ways. You know, I wanted to take this opportunity while we're setting the stage for the big picture. Recently, I saw you give a presentation. There was a couple graphics that I thought would be extremely helpful. And if we can pull up the first one, Tessa, is talk. It is talking. about some of the symptoms of menopause as they relate to aging, first starting with,

I believe, perimenopause, right? And then over time. And I think this could be very helpful to ground some of the conversation visually, especially for those that are watching on YouTube. Could you walk us through this graphic over here? Oh, I would love to. So I think it's critical to realize that we're starting at age 35. So depending on how attuned you are to these symptoms, you may notice that you're having more cramping.

Your period might get a little heavier. It might get closer together, as we talked about. Maybe you're not sleeping quite the way that you used to. Maybe you're having vaginal dryness or weight gain. Or you've got fibroids that are growing. So all of that can start around 35 to, you can see a dotted line on this particular graphic, right around age 43. And 43 is important because 43 is when the brain becomes more resistant to the function of estrogen. So there's less glucose metabolism.

So the mitochondria, the powerhouses in your brain cells just aren't picking up glucose the way that they once did. Glucose tends to rise peripherally. So if you have a continuous glucose monitor or you're checking a fasting glucose, you might find that it's climbing over this period to about age 43. So all of those things are happening in the background. And then if you keep in mind that age of 43, and then you look at the symptoms that are listed on the upper half of this graphic, most of these are brain symptoms. So mood swings, loss of libido, hot flashes, insomnia, night sweats, even the irregular periods, depression. All of those are brain symptoms. So a lot of people think that the action is in the ovaries, that you're, you know, not producing an egg every single month. You're running out of ripe eggs. And so estrogen and

progesterone levels are changing. But it's really, I think of it more as this bigger system, a network between the brain, the hypothalamus, and the pituitary, the way that it's talking to your ovaries, the way that it's talking to your adrenal glands, which is where you produce cortisol, as well as these other sex hormones that we're talking about, estrogen, progesterone, and testosterone and cortisol. And it's also involving your gut, because your gut is a really important source of hormones. A lot of people don't realize that. They don't know that, you know, the fiber that they haven't been getting in their diet

might be leading to excess estrogen in their system. So we want to be thinking about, I call it the HPA TGG. So hypothalamic, pituitary adrenal, thyroid genital gut axis. Now, that's a total mouthful. But just to understand that it's not just the ovaries we're talking about, it's really this bigger system that we want to be considering. So those symptoms that are happening from about 43 until I would say about 55, those really tend to concentrate on the brain. And then after that, you get these more long-term consequences of running low on estrogen. And that includes osteoporosis, more vaginal discomfort, maybe even recurrent bladder infections.

You can have breast cancer. You can have heart disease. So those are some of the things that we tend to track, especially in the randomized trials that are done, like the Women's Health Initiative. And those are things that we think about in older women. And as I said earlier, there's about 100 symptoms that you could map to pari menopause and menopause, but these are really the ones that are the most common. And so in that period, if your last period is somewhere around 51, 52, you really have a dramatic decline in estrogen. The lower half of the graphic illustrates this significant decline in estrogen.

And that's critical because estrogen is the primary regulator of the female body. the primary regulator. And so as estrogen declines, a lot of women just find that they don't feel as vital as they used to. They've got more moodiness. Maybe they've got depression. They may have more anxiety. That's not listed here, but it's a consequence often of insomnia, and it also is related to which estrogen receptors are being stimulated because some estrogen receptors are anxiolytic, so they reduce estrogen. Other estrogen receptors are anxiogenic, so they increase anxiety. So there's all these symptoms that women are experiencing, and we want to be looking at the total picture and not just saying, oh, you have insomnia, let's give you an ambient. That's not a

solution. That is masking symptoms. It's not getting to the root cause. You know, as part of this conversation, we're going to zoom in and zoom out a little bit. And I want to pick up on a thread that you just shared a little bit earlier, you talked about estrogen and the connection between that and fiber. You know, we know the stats that past individuals have shared in this podcast, which is, you know, average American, adult American is getting less than like 15 grams of fiber a day. So in that particular instance, especially for individuals that are going through perimenopause and getting closer menopause or maybe in menopause, if they don't have adequate dietary fiber in their diet, right?

How does that actually show up as symptoms they might be dealing with inside of the body? The way that I think of it, Drew, is that estrogen and progesterone are like tango partners. And you want to have a really good dance between the two. You want it to be well-balanced. You don't want one to lead or, you know, one to be dominant. And so having this balance between estrogen and progesterone is something that I want, women to focus on, regardless of their age. So if you're 35, 40, 45, 50, et cetera, focus on the balance between estrogen and progesterone. So the fiber becomes important because if you don't get

sufficient fiber, if you, I think of fiber as in some ways inactivating estrogen. So the golden rule of estrogen is that you want to use it and then you want to lose it. So you want to use it, to stimulate your receptors, and then you want to poop or pee it out. You don't want it endlessly recirculating in your body, usually through your gut, almost like bad karma. You want to be able to get rid of it. So fiber helps you to get rid of it. The other thing that you want to think about is that there are three bacteria in the gut that produce an enzyme called beta glucuronidase, or BG for short. And if you've got too much of these particular bacteria, you might have a high level of this particular enzyme, and that can be associated with higher estrogen levels.

So fiber, I think, is kind of the easy thing to reach for here. We know that the average American woman gets about 14 grams of fiber, as you said. And they should be getting somewhere around two to three times that. So the way I frame it is I want you to be eating about a pound of vegetables a day. You know, divide it up. Put it in your smoothie, if that sounds like an outrageous. amount. Get it in your salad at lunch. Have your steamed vegetables plus a salad at dinner. You need to be getting about a pound a day. So my recommendation is generally somewhere around 30 to 40 grams of

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t r y armra a rm r a dot com slash d hr u to get 15% off your first order today. Thanks for zooming in for a moment there. Now I want to zoom out again and look at sort of things from a little bit more of a evolutionary biology lens even though that is not either of ours background, but you are more qualified to be able to like at least try that hat on. What is going on in our modern world especially that has changed life so significantly for women that when women look around, they see a lot of examples of people essentially abnormally aging is what you have shared and kind of called it a little bit early in the interview. So what has been going on these last 50, 100 years that we are looking at things that are these whole host of symptoms that you were saying?

Some, if I understand correctly, and please correct me if I'm wrong, some aspects will be a natural part, right? It's not that like certain things will just never exist, but to the degree that which they exist is part of what you're highlighting, that it doesn't have to be that way. Is that accurate? That's accurate. Yeah, I would say there's a number of different forces that have really changed over my career, what I see with women. I mean, certainly we see the obesity epidemic, this crisis of metabolic health. And I think there's a number of different factors. It's not just one thing. It's certainly the food industry and how food has become more hyper palatable. We've got such a high intake the highest ever of ultra-processed food, and that has changed our system. I mean, we just, our bodies can't produce

hormones as normally as they used to, eating the kind of foods that we're eating. Would you put that as number one on your list? Well, it's hard. Maybe together we could pick what the top one is because I think along with that, and there's some interdependence, kind of bi-directionality here, is the rise of stress and trauma. So we know that, especially post-pandemic, we're more stressed and more polarized than we ever have been before. So when you think about the stress response in, you know, whether you're listening to a news cycle or you're just trying to cope with, your kid going off to college and some of the things that they're facing, I just feel like stress is an all-time high. And we're not equipped to deal with stress the way that it's coming at us right now.

And this is another important sex and gender difference. So sex differences are biological gender differences are more socially constructed. We know that women experience more stress than men. So if you look at national surveys by the American Psychological Association, for example, it's somewhere around 60% of women, experience significant stress, whereas it's more like 50% of men. So women seem to experience more. We also have, again, post-pandemic, I think more trauma globally than we've ever seen before. And whether that's losing someone in the pandemic or it's,

climate change and what it's doing to your community, the risk of floods and hurricanes and that sort of thing, I think we're managing more stress than ever before. And alongside that is the availability that we have with the use of cell phones. So more stress and women have more vulnerability, so a higher stress load, a higher cortisol load. And then they, in addition, When men and women are exposed to the same stressors, the same toxic stress, women have higher rates of post-traumatic stress disorder. So I think when you look at this more evolutionary perspective, we're at a time in our lives where there's more hormone disruption than I've ever seen in my career. So another thread is the chemical industry. So the kind of toxins that we get exposed to endocrine disruptors, if you just look at something like bisphenol A, drinking from plastic bottles, as an example.

Bisfenol A is not just a xenostrogen, a fake estrogen that stimulates receptors and can cause problems. It's also an antigen. So it can mess with your androgen levels, including testosterone. It's also a thyroid disruptor. So it's one of those chemicals that can really influence your hormone levels, and you may or may not know about it. So those are some of the things that I think about, but I imagine you've thought about this too. Maybe you want to add to the list. No, I think that's a great recap of the top things that are there.

And all those added up together, even though they happen very gradually, it's an important reminder that this is not the environment that we were meant to thrive in, which is why so many people, and in this context here, we're talking about women and the symptoms that they're going through and the challenges that they're going through through perimenopause and menopause, why there is so much suffering that's there is because we're living in an environment that our bodies cannot handle anymore, and they're tipping over from all the different insults that they're being exposed to. So I think that summary was a perfect summary. It's such a good point because you're speaking to this mismatch between our genetics and our environment.

And I feel like a lot of us create our lives, architect our lives, kind of doing the best we can, learning from our parents, whatever we were modeled by our parents, we come up with, okay, this is the career I want to pursue. Here's where I'm going to go to college. Okay, I'm going to get married in my 20s. here's who I'm going to marry. There are ways that we set up our environment that may not be the right fit for our genetics. And so really taking a close look at that, I think, is really valuable because a lot of hormone and balance is related to that mismatch that you're talking about. So, for instance, I had a job where I worked in McMed Medicine.

I worked at a health maintenance organization. I was seeing 40 patients a day. I was stressed out of my mind. I had two kids. I'd come home and I would pull up in the driveway and I would just sit there and vegetate for about 10 minutes, just trying to muster my energy to go be who I wanted to be with my children. You know, like show up with my love lights. That was not a good job for me. And so I had to figure out, okay, I got a mismatch here between my system, my network of my body, my genetics,

the way that my genetics are being expressed in my body and this environment that I've created. And so I had to change it. And so that's one of the things that I want to give people hope about, that you can make a lot of changes with your environment so that you may not be cursed by hormone imbalance, you know, for years on end. I want to piggyback on that because I've also heard you share that one important reminder that you share with many of your patients and that you talk about. in your different educational videos and books, is that when you start to talk about getting your life back in control and having agency on your health, which is you being the CEO of your health,

sure, you can hire different people, you can have a different doctor, you can bring people on board as part of your team, but you're the CEO of your health, when you do that and you start to look at the things, and women start to look at the things that might be necessary to start feeling better, it can feel very overwhelming. But even that feeling of getting very overwhelmed and not having the same maybe tenacity

that you felt that you had years ago, that itself could be a symptom of disruption in hormones. Is that accurate? It's a really good point because I hear about overwhelm all the time. And I've been there myself. Like I know what it's like to be given advice. Okay, I need to, you know, get on my. Peloton five days a week. I need to do power zone training. Oh, I need to eat differently. I need to like decrease my carbohydrates. And I need to do that together with, you know, having these two

kids that I adore and have full responsibility for. And I've got a husband like managing it all can be totally overwhelming. And you're right. It's important to realize that that often is a symptom of this time of life. So this life cycle change from our reproductive lives and kind of having the regular same level of hormones each day of a hypothetical 28-day cycle to having things be more wonky in pari menopause and menopause, it's really common to feel like you just can't handle one more thing. You just can't. So I think it's important to realize that that's a symptom. It's not like a permanent state of mind. And then I think it's also important to realize that when you start to correct these hormonal changes, I think of them as the hormonal Charlie's Angels. So when you

start to correct cortisol, when you start to correct estrogen, and you start to correct thyroid, and you get them back into balance, you may notice that the overwhelm disappears. So agency, I think, is really critical here. And in some ways, kind of a leap of faith that as you put in the work to get your hormones back into balance, that feeling of overwhelm may dissipate. You know, you have a incredible graphic. It is the hormonal Charlie's Angels. And I think the visuals are also very helpful. Again, if you're listening on audio, we'll link to maybe this image with your permission in the show notes as well. So let's describe this image here, the Charlie's Angels of hormones, as just a bit of a recap of what you were sharing. Yeah, I mean, there's so many hormones that are critical for women,

but these are the three that I focus on the most as a clinician. So cortisol is the main stress hormone. It is the priority in the body. And it governs your blood sugar. It's also involved in managing your blood pressure and your immune function. So a lot of people who are trying to get their hormones in balance and they're making their way through pari menopause, they kind of leave out cortisol, and that's not doing them any service. So you want to focus on cortisol really first and foremost. So you can get away without having estrogen. Like your body will survive without estrogen.

Your body will not survive without cortisol. It is the priority. So it's not a democracy in the body with all these hormones. I would say the two most important are cortisol and insulin. So when you think about the female body and these three hormones, the Charlie's Angels of Hormones, cortisol talks to thyroid. So a lot of women experience, especially after 40, what we call thyrapause. So that's this gradual change in terms of thyroid function. Usually it's in the direction of low thyroid function or hypothyroidism.

can sometimes be in the other direction, hyperthyroidism. And somewhere around 90 to 95% of thyroid dysfunction is related to autoimmune disease. So I'll just kind of asterisk that. Maybe we can come back to autoimmune disease. Absolutely. But thyroid is, you know, pretty much every cell in your body has thyroid receptors. It affects your metabolism as kind of like the gas pedal. If you think of your body as a car, it's critical to energy production.

and then we've talked a little bit about estrogen. It is the primary regulator in the female body. It regulates menstruation. It builds the uterine lining to prepare for pregnancy if that's something that you want. And if you don't get pregnant, then you shed your lining. It also keeps women lubricated in terms of their joints, in terms of their vagina. It's got about 400 jobs, so I just have two that are listed here. But we want to be thinking about, you know, okay,

maybe you notice that your shoulder has become more stiff. Like you don't have the mobility that you used to have in your shoulder or maybe the same thing in your knee or your hip. And if you're someone who's in that age range of like 40 to 45 to 50, you want to be thinking estrogen. You want to be thinking about, okay, seems like my lubrication just isn't what it used to be. And so we can track all of these hormones. We can track these Charlie's Angels of hormones.

And then I also, I like to just mention for the guys, I think of it as the three amigos. We want to be really considering testosterone, thyroid, and cortisol in men. And one interesting thing that I learned from your content is that also for women, testosterone plays a big role in their health. And is it accurate that it's the most abundant? Like, it's more abundant than estrogen? Yeah, testosterone. If you, if you're someone like me who gets a hormone panel once a quarter and you look at the concentrations of your different hormones, the one that has the highest concentration is testosterone.

It is the most abundant hormone in the female body. We think of it as a male hormone, but it is so critical for women, so critical. And if you think about confidence and agency and just feeling like, you know, you get up in the morning and you're ready to face your day. A lot of that is testosterone. I didn't pay as much attention to it when I wrote the hormone cure because my testosterone levels were fine. And then I found, you know, as I wrote more books, my last book in particular, Women, Food, and Hormones, that my testosterone was on the decline. So that got me to pay a lot more attention to it and to track my levels over time. And then once I dip below a certain level, I started to use

bioidentical testosterone. That's made a huge difference. So yes, testosterone is so critical. We think of it as important for muscle growth, it's one of the growth and repair hormones. It's an anabolic hormone. So especially at night, it helps you with, you know, seeing a response. If you're someone like me who likes to lift weights, you should see a response. And testosterone is one of the mediators of that. Certainly it's involved in sex drive. We all think of it in that regard. And that's true for men, too, in terms of their sex drive, their muscle response to exercise. It's also critical in terms of mood and anxiety. So men need to have a certain level of testosterone, and women do too. So even though men have a lot more, you know, somewhere around 10x,

what women have. Women are still exquisitely sensitive to it. And so we want to make sure that they've got the right amount of it. That's fantastic. Just a tiny little sidebar, because I'm always getting my labs done. Last year when I turned 40, I was really inspired by a mutual friend of ours to start taking strength training way more seriously than I did, Dr. Gabriel Lyne. So I did a full body composition measure. I did it right after a big trip to Italy, so that probably wasn't the best idea, but it was very motivating. I remember that trip. It looked like a lot of fun.

It was a lot of fun. I had a blast. My wife was there. My friends were there. Their wives were there. We had such a good time. A few of the guys were all turning 40. Came back, did my body composition and was shocked in a good way and motivated in a good way.

And also got my labs done. And I saw that my testosterone was in the sort of normal but not like optimal, right? I think it was like came in around like, low 400s, right? And then just through primarily improving my body composition, adding lean muscle mass, strength training as a byproduct of strength training three to four days a week, because I wanted to take it seriously, upping my protein, which is a big part of it. I kind of grew up under eating protein and being on a more vegetarian diet. I was vegan for seven years before I, you know, discover the world of functional medicine, integrated medicine and completely

changed how I operated. And in less than a year, I increased my testosterone by almost 100 points. Just through that, no testosterone patches, you know, no prescription testosterone. And it's just such a reminder of how powerful the body is when we create the right environment for this. And I can imagine that you've probably had female patients themselves also too, because you're a big fan of resistance training have seen their own improvements, you know, hormonally, just by putting some more intention into this area of resistance training. Such a critical point. You know, I feel like in the debates that we have scientifically about low testosterone

and men or low testosterone and women, it tends to be this polarized conversation about should we do testosterone replacement therapy? And what gets lost is the lifestyle changes that can really make a difference with your hormones. I mean, if you think about it, the food that you eat is really the backbone of the hormones that you make. And then the way that you are utilizing your body, like if you're using it the way that it was intended, you know, our ancestors on the savannah were not sitting in chairs and sedentary. They were moving around. They were lifting boulders.

they were doing what we approximate now with strength training. And I think it's really critical. So to see that kind of change to have this bump in your testosterone just with lifestyle change, I think is so important. So yes, protein consumption has been shown to make a difference. Reducing sugar has been shown to raise testosterone. The way that you exercise, like with strength training, can really make a difference. And then for some people, you know, even taking some of the precursors, like DHS,

which is over the counter can help to raise testosterone. That especially works in women. It doesn't work quite as well in men. It tends to be aromatized to estrogen, so you have to be careful about that. But I love this point about how lifestyle change can cause significant changes in your hormone levels. And I imagine you felt a lot better, too. Yeah.

I felt incredibly. I felt like there was a little pep in my step. Yes. Which is what a lot of people notice. You know, I want to take some of this, and I want to contextualize it in your story and of course your books where you have fantastic protocols that you've written that women can follow. We have the links to your books in the show notes below. When you went through this moment of having gone to your doctor and him giving you a birth control pill and an antidepressant

and saying, you know, lose a little weight, eat better, or lose a little weight and move a little bit more, and he said, there's got to be a better way. I'm sure that sent you down this whole hero's journey where you started to unpack some of the core aspects that were within your control, these different levers that you could start to pull to feel better. And because I've seen you educate to patients, and you're an incredible educator, you're really good about sort of chunking them to help patients figure out where to start first, second, third, and then kind of continue. So where did you start in your,

own journey as you started to peel back the layers of the onion and look at this interplay of the hormones and see that a lot of what you were dealing with was essentially from a biological lens abnormal version of aging that women go through and that it didn't have to be that way where was one of the first places that you started and prioritized in your journey to make a shift the first place was cortisol so i left that doctor's office and I went straight to the lab. And yes, I've got medical training, and so I could order my own labs,

and I realized a lot of people don't have that. But I decided that I was a hormonal hot mess, and I just wanted to see what my levels were. And this is from conventional training at Harvard Medical School and MIT and UCSF. Like, we weren't taught to just run a hormone panel. when you don't feel good in your late 30s. So this was a bit of a hunch, but I found that my cortisol was about three times what it should have been.

And that was my first clue because my other hormones were off, but they weren't off as much as my cortisol was. So I paid attention to my cortisol because it was three times really what I considered to be normal. my thyroid was a little bit off, my TSA was a little bit high, thyroid stimulating hormone, which tells me that my brain was shouting louder at my thyroid to make more thyroid hormone. But I also realized that could be secondary to the cortisol. There's a few other factors involved that we'll get to. And then looking at my estrogen and progesterone, estrogen was a little bit high compared to progesterone. Again, late 30s, you start to run out of,

these eggs, you start to run out of ripe eggs, and so progesterone tends to decline. But cortisol can also play a role in that. So it seemed like the primary problem to face first was cortisol. Why am I spending so much time on this? Because I see this all the time in the people that I take care of. More women than men. I take care of both. Women have more dysregulated cortisol than I see in men. So this really high cortisol level, I remember when I first saw it, I called one of my mentors at UCSF. And she's a psychiatrist who orders cortisol on our patients because she uses it as a suicide marker. And she also tracks it in depression because about 50% of people with depression have high cortisol. And she said, welcome to the club, Sarah.

Every female physician I know has a cortisol that's two to three times what it should be. Wow. And I thought, okay, it may be normal, but I don't want to be normal. Like this was before I saw that study that showed that you can have brain shrinkage in your 40s associated with a high cortisol level. But I had a sense in my 30s that, okay, this is what I really need to manage. I need to get this under control. So I had a little bit in place already. I was already a yoga teacher.

I kind of needed it to manage my cortisol. I didn't know cortisol was so high, but I had a sense in my body that I needed it. I really felt like yoga and meditation for me were non-negotiable. And still, I would skip it on occasion. I had two kids, like toddlers. Life was busy. Life was busy. And I was still working at the Health Maintenance Organization.

So I made yoga and meditation non-negotiable, 30 minutes, every single morning. No excuses. that helped a lot. How quickly, if you don't mind me interjecting, how quickly did you notice a difference once you made it a priority every morning, a shift in your mood that you could notice? I would say within a week. I mean, and you're a meditator.

Yeah? Not really. Not really. Well, have you ever... I've gone through long periods of my life. Yeah. Where I've been very good about meditating. Yeah.

I've gone through long periods of my life where I haven't meditated, but I'm not ashamed to say that I'm not a daily meditator. I really appreciate you sharing that. I think it helps for people who are listening to us and they're thinking, why can't I meditate? So, but you've probably had the experience when you were meditating regularly of some days that just, oh my gosh, it just feels like the stars aligned and you just feel so good after whatever time you committed to meditation, you get up off the cushion, and it just, you know, just feels like, oh, that was a good one. So there are days like that that I think accelerate

this recovery with the stress response system, and they create balance between the sympathetic nervous system, kind of the on button of your autonomic nervous system versus the parasympathetic nervous system, which we're activating with meditation. So there are some days that are better than others, but I would say on average about a week. That's when I really notice a change. So cortisol was the first place you started and prioritizing the sort of rest and recovery aspect. Rest and recovery. And let me layer in a couple of other things. At the time, I was a runner. So I was running about four miles, four times a week. And so when that doctor said to me, you need to exercise more and eat less. And I just knew in my bones that that,

I was wrong. I started to look at the literature on running and I realized, oh, I'm already a high cortisol person. I go running and I'm raising my cortisol even higher. I wasn't doing any strength training. I was doing chronic cardio at that time and that was adding to the problem. So high cortisol kind of day in and day out. And I was still one foot in conventional medicine, one foot in this more functional integrative medicine world. And so I still had this idea, well, is there a pill like a dick? So I started looking at the literature on supplements because I was thinking, well, there's all these adrenal tonics, right?

Like aschwaganda and ginsings and couldn't those help? Rodeola. And there is quite a bit of literature showing that rhodiola in a randomized trial reduces cortisol levels. We know that Oshwaganda seems to reduce cortisol levels, at least in animal models. There's not as much human data, but it's got, you know, thousands of years in Ayuveda of being used. Phosphatil serine at a dose of about 400 milligrams. It's been shown to lower cortisol. Same thing with the mega-3s, with fish oil is what was studied in the randomized trial. So there are supplements that can help. And so I layered that on top of the, the

Yoga and meditation. I changed the way I was exercising. So I stopped being, I still ran occasionally, but I started working more, working out more with friends, and that provided accountability and community and more attending and befriending and kind of conversations about these things. I started doing more adaptive exercise, more Pilates and ways of working with my core and not chronically raising my cortisol level. So those things together, I would say over about a six-week period really made a difference. So I felt a difference at a week with the yoga and meditation, but it really took about six weeks to reach this new steady state,

this new homeostasis. And is cortisol, which goes into this whole perceived stress and women experiencing more of this perceived stress and real stress inside of their day-to-day lives and often the burden of family and sort of world events because they feel everything. much more sensitive in a beautiful way. They notice what's happening in this world. It's their superpower. Do you feel that for most women who are listening today, that that often is the best place for them to

start? You started there in cortisol and stress management and everything like that, changing how you worked out. Is that what you find is where most women could benefit starting from as well? I'd say about 80% of the patients that I take care of need to start with cortisol. So occasionally I'm surprised. You know, I've had maybe 5 to 10% of my patients have completely normal cortisol levels. I also have some patients who've got cortisol issues, but they've got other hormones that are a bigger problem. Like they've got hypothyroidism. They need that addressed.

And then we can work on the cortisol. So I would say 80% of the time cortisol is the one to start with. And so there's lots of ways you can measure this. to kind of see what the highest priority is. And I love that we're democratizing data. I love that you can go to different labs and you can actually order some of these panels. I mean, certainly get it through your insurance if you can,

but there's still a lot of doctors who don't understand the value of doing hormone testing. That's kind of a whole other topic. But I love that we can go to different labs now and you can order a panel when your clinician, may not want to. Yeah. And in the case of cortisol now, the best panel order, is that going to be blood or saliva if somebody has the resources to be able to do it?

So I start with blood. The problem with blood is that it looks at total cortisol. It doesn't measure the free cortisol. So my preference is to use saliva to look at cortisol. And if we want to go a little bit more granular, what I like to do is a diurnal cortisol, and that's where you measure it at four points during the day. usually when you first wake up around noon, 4 p.m., and then before you go to bed. And it should be almost like a gazania, where the cortisol goes up first thing in the morning,

then it has a gradual decline while the sun is up. There's also something called a cortisol awakening response, and that's where you measure your cortisol in the saliva. When you first wake up, 30 minutes later, 60 minutes later. And those help to tell us whether the control system is working. with your cortisol. You know, one of the top things that women who wrote in when I was talking about doing this episode is how much they notice their sleep cycle is being thrown off, especially as they are noticing symptoms of perimenopause, and then usually when menopause happens, that one-year

marker after having their last, you know, period, there's so much disruption they notice with sleep. And I can imagine that cleaning up our sleep hygiene and prioritizing our sleep is a big part of what also helps us get our cortisol levels in check. So how do you think about those things together? The struggling with sleep and the symptoms that are often associated with that, waking up in the middle of the night, which a lot of women experience, but then also needing to prioritize sleep to make sure that you're recovered the next day and to start having cortisol being. in a better range? Sleep is a complicated topic. And I'm really glad you raise it because we know that women suffer from insomnia at double the rates that men do.

So there's something different about female physiology. And I also should say that I'm talking about men versus women here with the recognition that, you know, we're talking about those who are assigned male at birth and assigned female at birth, and there's, you know, an infinite number of experiences between those two poles. So I'm using it, I'm using men versus women mostly because that's how the science gets reported. But I want to acknowledge that there may be a lot of different folks in our audience who identify in a gendered way or not gendered. So with insomnia, you know, I think of a lot of different factors here. When I think back to my 20s. And I want you to think back to your 20s too, Drew. I mean, I was going through my medical

training, so I had the stress of that and being on call. But really, I didn't have many other responsibilities. I didn't even have a goldfish. I didn't have a dog. I just had an apartment and I would just go back and forth to the hospital. I had very little to manage other than the career that I was starting. And then I think of my life now where I've got, you know, two older daughters, that are adult, and I've got parents that just moved to assisted living. And I think it's a good representation of how the number of things that we juggle as we get older really changes. So a lot of women who are in this transition of perimenopause and menopause are in that sandwich generation, where they're managing their parents and some of the changes they're experiencing with their

health. And then they're also managing children. And so the demands, the kind of things that you can obsess over, the lists of things to do, the ruminations really increase exponentially. So that is one thing that conspires against you in terms of sleep. And I'm curious if you also have kind of seen a difference in your sleep maybe compared to your 20s? What have you noticed? I've always been a really good sleeper, especially my deep sleep when I track it using my whoop. I've always been a pretty good sleeper. The only thing that's impacted me, which is a completely different topic, is I've noticed that it's really interesting that after I'm happily married, my wife's awesome, Yasmin, prior to my relationship with her, a few years prior having met her, I went through a breakup. And it was a pretty

stressful situation. You know, we both cared about each other, but the circumstances were, you know, very tough situation. Ultimately, it didn't end up working out, but we had a lot of love for each other. I noticed that after that period, which, again, a lot of people notice after very stressful periods, could be a breakup, could be a business situation, divorce, this, that, whatever might be, I started grinding my teeth at night for the first time. And at the same, and at the same, and at the same time I also got Invisaline done, so I feel like my jaw structure changed a little bit. And I would notice that I was developing a form of almost like an apnea at night where I'd be grinding my teeth. And surprisingly, mouth taping was very helpful.

And then getting something which a few dentists have talked about on this podcast before, I found a really great dentist here in L.A. And he put me on, it's called a dental appliance. And it created some expansion in my mouth. Once I did that, everything improved. But again, I'm not going to be the typical situation that other people are there. But yes, most people, even when I look at my mom when she was going through this phase of her life, of entering into menopause, she generally was a really great sleeper and started noticing she was having all sorts of bouts with insomnia that she didn't deal with previously. And it was really tough on top of that.

she was struggling with some changes in her digestion. And she was having a lot of challenges with acid reflux, which were also keeping her up at night. In fact, it got so bad at one point in time that we thought, okay, did she develop, you know, later in life sort of anxiety that was there? And she was even given, you know, anti-anxiety medication for a period of time. And luckily, knock on wood, we found an incredible practitioner who said, look, it's a cycle that

she's in of the acid reflux is preventing her from sleeping well. And because she doesn't sleep well, she's going essentially, she's having all this anxiety and her cortisol levels are really high. If we fix the acid reflux in her situation, again, this is what she was going through, we're going to see she's going to start to sleep well, and she's not going to have these symptoms look like anxiety on the surface. during the day. And that's exactly what happened. This E&T doctor, who specializes in this, helped her fix her acid reflux. And that was her end of one situation. And she's back to sleeping better,

but still dealing with these various ballots of insomnia that come occasionally. There's so much in which you've just described. So the description you gave of noticing that your sleep changed and that you had bruxism, the grinding and clenching of your teeth at night, when you went through this breakup, it's so critical to notice that because I feel like for women who are going through this life cycle change, they have a lot of kind of small tea traumas that occur. And they're just trying to manage it all. and they may notice that their sleep becomes more disrupted, and then you superimpose the changes that are happening with estrogen and progesterone,

and it just starts to accelerate the whole process. And then, as you described, once your sleep becomes disrupted, it affects your cortisol the next day. It raises your insulin level. It makes you crave carbohydrates more the next day. And so you can have this domino effect that is adding together with, the metabolic changes that we described at the beginning. So it's really critical, I think, to dial in sleep. It is as close to a panacea as we have when it comes to health. And I love

this example that you gave also of your mother, because I don't know if that E&T practiced functional medicine. Integrative medicine. Integrative medicine. So there's so many different ways that we can work with acid reflux, short of just using a people's, you know, just using a people's And so I think it's really important to do this root cause analysis, which you're able to help your mom do. And it can make such a difference when it comes to sleep. Because often someone like your mom ends up on at a van, you know, like an anti-anxiety medication. She ends up on a proton pump inhibitor, a PBI. And then that causes other gut problems downstream.

And that's kind of the standard model of how we deal. with that. And then maybe she gets a little sleeper added to the mix. And so here we are masking all of these symptoms and we're not addressing the upstream causes. So what we want to do is we want to do this root cause analysis. So back to, you know, what women are up against, when you've got this decline in progesterone that happens in the first half of perimenopause, that can cause sleep disruption. So you're running out of right bags. You don't make as much progesterone if you do a serum progesterone level on day 22 of your cycle and you check it every three to six months.

You might notice that it's not quite as high as it used to be. It may not be 15 anymore. Maybe it's nine. Maybe it's seven. Maybe ovulating, you may not be. And so the first thing I like to do in someone who is having trouble sleeping and say they're between 35 and 50, all do progesterone. because progesterone is nature's valium.

It's really like an anti-anxiety medication. You'll prescribe them progesterone? So it's a somnolent, meaning that it helps you sleep. And there's multiple randomized trials that show that it's really helpful for women who are impairing menopause. So that's typically where I start in someone who's cycling. I'll add a little progesterone because they're probably not making enough. And we can confirm that. And is that typically topically or is that in pill form?

prefer oral because I think that helps with sleep much more than transdermal. The thing about transdermal progesterone is that it's really not well proven to make much of a difference in terms of your serum levels of progesterone, kind of what your receptors are seeing. I use it sometimes women who've had a hysterectomy, but otherwise if you have a uterus, I like to use oral, or if we're treating sleep. I like to use oral. So you mentioned that was in like 35 to 50. And what What about for women 50 plus? So 50 plus, that's where we're going to start to bring in estrogen. So I like to start in the first part of perimenopause with progesterone only as treatment.

And you could do an end of one experiment. You could try progesterone for three months. Just see if it affects your sleep. And side note, I love to be tracking sleep so that we're looking at some of the metrics you mentioned, like deep sleep, REM sleep. How many interruptions are there? What hours are you sleeping? consistent are you? Is it lining up with your chronotype? So I like to measure sleep because I think when you look at it with that perspective and you've got objective data, you can really track it and

you can do these N-of-one experiments and see if progesterone makes a difference. So after 50, kind of depending on the woman and what symptoms she's having, if she's still cycling or not, I'll add in some estrogen. And typically at that point, if we're addressing sleep, it's going to be an estrogen patch, a bioidentical estrogen patch, such as the, can I mention brands? Yeah, absolutely. So, Vival dot, I love 0.0375 milligrams in that sort of situation. So progesterone, I'm assuming there's some estrogen dominance and a small dose of an estrogen patch, and then we see if it improves sleep. And some of the things I'm looking for in terms of symptoms, I'm looking for insomnia, so changes in sleep. I'm looking for objective data. I'm looking for

objective data. It's one of the reasons I wear an aura ring. You have a whoop. And I'm also looking at night sweats, hot flashes. And in women who are still cycling, sometimes what they have is night sweats, just the week before their period. And that might be when they need extra progesterone, just during that week. Whereas women who are older, they're more likely to have hot flashes, like during the day, not just at night. So this was all in the context of cortisol. addressing, as you had mentioned, for 80% of women, that often that's a great place to start is sort of helping to think about perceive stress, the management of that, and bringing cortisol down because high cortisol levels has a whole host of implications on the whole concert of hormones

that are there. That led into the topic of sleep and your suggestions that were there, which also encompasses a top question that people had, which was biodendical hormones. hormone replacement therapy, et cetera. So we touched on that a little bit. Let's come back to the sort of sequence of things that you did and that you recommend now that you have a sense of things with cortisol and the listeners have a sense. What is the next place to move on to?

So in my case, I focused on the thyroid next. So you can run a thyroid panel and see where you are in terms of thyroid function. And I've got the normal lab ranges in my book, The Hormone Cure. So there's a whole chapter on the thyroid. And generally what I like to see with the main test that we do, which is thyroid stimulating hormone, I like to see it somewhere around 0.3 to 1.5 to 2.0. So if it's above that, I'm starting to look more deeply at whether there's some other issues that are affecting thyroid function.

So, for example, if I've got a patient who's got a TSA, that's six, and she's got low T3, that's someone that I'm going to start treatment with thyroid hormone. And we talked earlier about how a really common issue that drives the root cause of thyroid dysfunction is autoimmune thyroid disease. So Hashimoto's is one of the most common. And we know that Hashimoto's has been increasing in prevalence. mostly affects women, although I've got male patients, too, who have it. And so along with the thyroid panel, or what I consider part of a thyroid panel, is to look

at thyroid antibodies. So autoimmune disease is when your body has difficulty telling the difference between your normal tissues and tissues that it's recognizing as abnormal and then attacking, usually with the antibodies. So you can measure those antibodies. This is the topic of my next book, because what I noticed was that I was seeing more and more people with autoimmune disease who were coming to see me. Things like Hashimoto's, multiple sclerosis, rheumatoid arthritis, lots of different. There's 100 different autoimmune diseases. And I was seeing this increase in prevalence, which has been seen globally. So about 5% of the world population right now has autoimmune disease.

about 25 million Americans have autoimmune disease. And I also was noticing that it seemed to a very common trigger for autoimmune disease is toxic stress or trauma. So that's what got me to focus on that in my next book. But when it comes to the thyroid, what I suggest is that you do a panel at least once a year to look, to look at how your thyroid is doing, how it's functioning. One of the most common things I see in people who don't have hypothyroidism is that they may have a normal T-SH, but they may have a low T-3. And T-3 is the three refers to the number of iodine atoms that's associated with the hormone. So T-4 is the storage thyroid hormone.

You take off an iodine, and that gives you T-3. T-3 is biologically active in the body. it's stimulating all those receptors that are throughout the body to increase metabolism. So with what I see commonly, and this is often a cortisol effect, is that people aren't converting T4 to T3. So they have poor conversion. And that's something that you can correct. There's lots different reasons for it. I would say stress is the most common. And also typically the panel that would be ordered, it can vary from doctor to doctor. So I'm imagining in your book, you have an expanded panel that, you know, you can ask in a polite way. And if your doctor

doesn't respond, go look for another doctor and get the complete panel. So, for example, would thyroid antibodies be something that you'd be asking for additionally to also look at sort of the autoimmune component of it? I would recommend that. So I think everyone should have thyroid autoimmunity checked. So what I order in a thyroid panel is a T-SH, a free T-3, a free T-4, a reverse T-3, and then thyroid antibodies. So thyroid peroxidase antibodies and antithyroglobulin. So that's the panel that I like to order. And what's interesting is that, you know, I hear all the time from women who go to their doctor and say, I ask for a hormone panel, including thyroid. I've got all these thyroid symptoms, and he tells me it's normal. But unless you're doing this deeper,

broader panel, you may not know the whole story. You know, a big part of what we do in functional medicine, in precision medicine where we pull together genetics, together with blood testing and other biomarker testing, we're trying to understand, like, where are your vulnerabilities? And so a lot of people who get told that their tests are normal, we know that there are folks who are included in that normal population that the lab reports who are hypothyroid. So if you look just at people who are U-thyroid, EU thyroid, they tend to have a TSA that's somewhere around 1.5. So we know what normal optimal function looks like. I don't want to be normal. I want to be optimal.

And so you want to know the difference between the optimal range with your thyroid tests versus the normal range. So your doctor may be telling you you're normal, but you might be wanting to be optimal. And that's a different goal. That's a great explanation. Thank you for that. I want to ask you in the context of this, and I know we have a few more. where does diet fit into it and what did your diet look like at the time? I know you've learned so much about diet over the years and you are a big fan of especially

a diet that prioritizes things like protein, balances blood sugar, and feeds our gut as well too. How is your diet at the time and what are your dietary recommendations for what? women that want to step into harmony with their hormones. Well, at the time, I think you're talking about when I was seeing my primary care doctor, and I got angry with his advice. So this is a bit vulnerable, Drew. You know, I would say when I was in my mid-30s up until about age 40, I was a food addict.

I was eating a lot of carbohydrates. I was... loosely following a Mediterranean diet. And I, you know, I was eating a lot of fresh fruits and vegetables, probably too many fruits for my system and for my blood sugar. And what I really discovered was that I was using food to soothe myself. And that's a very common reaction that men and women have, women more than men. and at the time I didn't realize that it was really an unsuccessful strategy.

So I was overweight. I was drinking too much wine. You know, it was a big part of coming home from a day of seeing a lot of patience. I would pour myself a glass of wine while I was cooking dinner and I'd have another glass of wine when I ate dinner. It was too much for me. Two glasses of wine was too much. and I basically couldn't turn off the fat storage until I really cleaned up my diet.

So there's a lot of different components to this. I'll try to keep it relatively simple. But I also urge caution here because what worked for me may not work for the next person. And this is where you really have to do some end-of-one experimentation. So I got into food recovery and that made a big difference. And I wrote about that in my first instance. second book. So there's a lot more detail there. But I realized that the Mediterranean diet actually caused me to gain weight. And so I had to do more of a low-carb version of the Mediterranean

diets, so still getting a lot of different colors, the rainbow with the food I was eating. I had to focus more on non-stargy vegetables, less on fruits. I had to eat more protein because I really found that helped to stabilize my blood sugar. And I needed a lot more fat. So those were some of the things that I had to change. And, you know, what I found was, I would say, about 35 to age 40, I needed to reduce my carbohydrates and increase my protein. In my 40s, I found that as my blood sugar was really changing pretty dramatically, that I needed more fat, and I needed more fiber. So those were some of the changes that I made. And then I found starting to around age 50 that I really needed to increase my protein because I was starting to lose lean

body mass. And that's really critical because there's so many women who lose muscle mass. And our friend Gabriel Lyon, I think, has written a beautiful book about this very topic forever strong. So I really encourage people to check that out. But after 50, I needed more protein and I needed to do these ketogenic pulses. I would do them for about four to six weeks. To get into ketosis, I found that it really helped me with the brain fog and with some of the cerebral hypometabolism or slow down in my brain function that I was noticing. And it really helped me to regain my metabolic health. So that's a bit of a tableau over time.

And what I encourage people to do is end of one experiments. And the thing that helped me with my N of one experiments more than anything else was a continuous glucose monitor. Well, I want to ask you about that. And before we go into a continuous glucose monitor, would you say generally because we have a whole host of people that are listening, some people that have been on their health journey for a long time, some people that are just starting, that within that end of one, there could be some broad strokes that could be applied to everybody. Yes. Getting off of ultra-processed food or highly minimizing ultra-processed food and shifting to more whole foods diet, regardless of how people. maybe even doing at some point in time, again, unless if you have some history with disordered eating and you might want to be working with a professional, but I generally

find for most individuals there's not really even a sense unless they audit their total calorie and protein intake. Like just doesn't have to be that the way that you are measuring your food all the time or tracking calories, but even for two weeks, getting a sense of like how much are you just eating in terms of total calories that are there from our diet. Yes. Healthy food today, process healthy food tastes better than ever. It's so easy to even overeat on that, those types of things.

And total calories, while they aren't the entire picture, they still matter, especially when it comes to body composition. So staying away from and minimizing ultra-processed food, maybe doing a little bit of an audit situation. Generally, most people are going to benefit from including and getting more diversity of fiber in their diet, as well as one of the last ones that would be there would be, we mentioned protein already. Yeah, anything else who would add to that mix that?

Well, I would say fat, I think really paying attention to fat. Fat is the backbone of all the sex hormones that you make. So if you think about the diagram of how sex hormones are made in the body, they're made from cholesterol. Yeah. A lot of people don't realize that. A lot of folks don't realize that. So cholesterol fat gets converted to prekine alone.

That's the mother hormone that goes on to make progesterone and cortisol and DHA and then testosterone and the estrogens. So getting quality fat, I think, is critical. Could you explain what quality fat is and some of your favorite sources for individuals? Yes. So I love fat that is from plants. I would say I favor that first. So avocados, coconuts, nuts, nuts, seeds. That's probably my favorite source.

Olive oil. I think we can all agree that that's really healthy. I am someone who's an omnivore, so I do really well with eating animal protein. I realize that's not true for everyone. But I love a wild game. And so I get fat from the meats that I eat. I tend to eat the cuts that are a little fatier. I think fish are a really great source.

I think the pescatarian diet is one of the healthiest that you can have. So I also like MCT oil, especially when you're doing ketogenic pulsing. I think it can be really helpful because it helps to, it's been associated with weight loss. And it also helps with alcohol cravings, if that's something that she's struggle with. So I think fat is really critical. it helps you feel satisfied longer, and it also helps you with blood sugar stabilization. On the topic of blood sugar stabilization, you know, which goes into continuous glucose monitoring, before we get into monitoring through a CGM, what do you feel are, you know, a couple of the most

important tests that people should be talking to their doctor about ordering to really get a sense of their blood sugar in the context of their metabolic health. Most doctors start with a fasting glucose and with a hemoglobin A1C. So those are pretty standard tests that you're going to get when you go see your doctor and you get kind of a basic blood panel. And those can give you a lot of information. So when I was working at the Health Maintenance Organization and I didn't have the luxury of doing a lot of functional testing, I really found that with,

with a hemoglobin 81C and a fasting glucose, I could get a lot of information and I could guide my patients in terms of dietary changes. So that's where you start. The problem is glucose changes kind of late in the metabolic health journey. So for people who are maybe eating too many refined carbohydrates, maybe they have a sweet tooth like I did and they're getting too many, too much sugar, what we know is that insulin changes first. Insulin changes. Insulin is what drives glucose inside cells. It's kind of part of the control system for your glucose.

So insulin can change seven to 14 years before your glucose changes. So most conventional doctors are looking at glucose, and you just have to be thinking upstream that it could be seven to 14 years of changes in your insulin before it shows up on your glucose. So my preference would be that we add on looking at insulin. Fasting insulin, ideally like a two-hour glucose challenge test where you're measuring glucose and insulin every 30 minutes after you have a certain dose of glucose, usually 75 grams. So those are some of the tests that I find to be helpful. And then I would say there's more advanced testing that you can do.

So I like to use labs like Cleveland Heart Lab. I like to do an insulin resistance score. I track something called a Homa IR for insulin resistance. I look at uric acid. So I like that to be less than five in women, less than 5.5 in men. I look at LFTs like ALT. when you have increased fatty liver related to insulin resistance, you may find that your ALT goes up. So I like to see an ALT in women less than 20, less than 30 in men.

So those are some of the basic things that I like to measure in terms of metabolism. And then it also can relate to inflammation. That's sort of another topic related to metabolism. But that's where I like to start. I'd love your thoughts on this. do you feel that it's possible for especially somebody who's in the menopause stage of their life, is it possible to feel significantly better without getting your blood sugar in control? I don't think so.

I don't think so. Let me just, let me think about this. So I'm trying to think if I have any patients with pre-diabetes, of which there are so many. And most don't know they have it. I'm trying to think if there are any people I know with pre-diabetes and diabetes who really feel well without addressing their glucose. And I think the answer is no.

I just think it's so critical to energy production, which is, you know, that's the fuel for your mission. It's how you live your life. So unless your glucose is under control, unless your insulin is on your side, I just don't think you can feel well. I figured you're going to say that because I know your content pretty well,

and I think it's an important reminder because when individuals, men and women, right, this conversation, we're mostly focusing on women, but men and women, especially you're in your later 40s, you're in your 50s, you're in your 60s, you're in your 70s, and you are starting to learn about the importance of balancing your blood sugar, it can feel like a lot.

If you've been eating a particular way your entire life and you've been on this glucose roller coaster all day long and you're used to eating that way, which means that you're probably snacking a lot, you're probably hangary a lot. Yes. You have a lot of refined carbohydrates in your diet. You might be going to sweet things a little bit more than, you know, what would be more tolerable for the body. you are under eating on fiber that would be there, and you probably are relying a little bit too heavy on processed food, whether that's ultra-process food or whether that's healthy processed food because a lot of healthy processed food can spike your glucose up and down all day long.

And when you start to zoom out and you think, man, my entire diet is designed to shoot my glucose up, and then I crash later on and I don't feel good. and then I do it all again. And you're used to that it can feel daunting to think how you're going to break out of that cycle. And why I think this is so important to remind people is that you've stated in previous interviews that there's no bigger habit change

that you have seen in your clinic than putting a patient on a continuous glucose monitor. Can you explain that a little bit, especially in this context of these habit changes being a little daunting for individuals? Yeah, I love that you framed it this way, Drew. I don't know that I've ever heard someone frame it the way that you just did because as you were talking, you were taking me back to my 30s and my early 40s when I know that I was so spiky with my glucose. I just know I was. You know, I would, I'd be at work. I would skip lunch because I'd be doing charts.

I would grab granola bar or something like that and that would spike my glucose and then I would crash. I had a lot of stress and that exaggerates the crashes even more and makes you more spiky. And it's all about the spikiness. Like the spikiness is the problem. What you want is kind of this steady curve with your glucose so that your body has a reliable source of fuel. and it's not going to, you know, kind of this alarm setting constantly. So as I think about the people that I see, you know, most of the time people are coming to me because they've got symptoms. They feel fatigued.

They feel depressed. They feel anxious. Their joints hurt. You know, there's something that brings them to me. And often when we start to kind of pull back the onion layers and we look at the gut and we look at blood sugar control and we look at how metabolism is operating, they're really surprised to find that these things are not optimized. and they're surprised that foods that they always thought were healthy are actually spiking their glucose, maybe even taking them up to pre-diabetic and diabetic levels. So I think unless you're measuring it, you really don't know.

And that's the part that I love about continuous glucose monitoring, because it gives you this immediate biofeedback on how your body is dealing with the muffin that you just ate versus the salmon and broccoli. And when you have that data, you have to act on it. Like it's, when you realize, oh, I feel so terrible after the muffin. And wow, look, my glucose didn't change at all when I had the salmon and the broccoli. Like, that is enchanting to get that kind of personalized information about yourself and you just can't ignore it. So it sets up this loop of integrity that I think otherwise people are missing. It's almost like what you don't know. Like you just, it's very hard to change behavior unless you have the subjective data that's saying to you,

Sarah Gottfried, when you eat a banana, your glucose goes up to 180. Like you can't go out and have the assaye bowl with your daughter every time you come to Los Angeles because your glucose is spiking way too high and then you feel like a hot mess the rest of the day, irritable, struggling, can't go work out at Soul Cycle like I used to love to do with her. And so it allows you to connect the dots in a way that I think is really critical. You know, to add to that, because I'm a big fan of continuous glucose monitors as well. I think we're both advisors to levels and we're big fans of them. We'll link to them in the show notes for anybody that wants to check them out.

It's also, too, that you can eat, in my experience, the banana, but have it after, you know, at the end of the meal. Because I think part of what you're also helping people understand is that, you know, we don't want to demonize any sort of macronutrient that's there. And interestingly enough, I found that, you know, even when you do things like you go into sauna, your glucose goes up, or you do a heavy workout, your glucose goes up. And those are natural responses that the body.

has that's there. So certain meals I would have, I'd go up. But what was great about eating a balanced, you know, like eating a blood sugar balanced forward diet is that when I shifted to that style of eating, which is largely the things that you're talking about, I would naturally have an up curvature and then it would naturally kind of come down without like looking like a big yo-yo throughout the day. And then when I started training a little bit more seriously than I was, I actually found that I could eat more carbohydrates than what I was eating at the time. I had pretty much stripped all refined carbohydrates out. I was starting to pulse in some white rice, especially in the days that before the day that I would work out.

And I found that my improvements in the gym were significant. And I also found, because I was tracking my fasting insulin, that my fasting insulin was staying stable primarily because I was adding lean muscle mass all throughout the process, and it's our lean muscle mass that's eating up all this glucose in the first place. Another reminder that you can actually just get away with eating some more carbs, you know, was my situation. If you're bringing in that strength training piece. Now, I wasn't eating 300 grams of carbs a day. I'm just talking about a little bit of additional carbohydrates in my diet when I'd pretty much stripped them out. And I generally noticed that I was feeling better. and my glucose was still, you know, mostly balanced my score.

At the end of the day, you get a score from levels on the app that was there. I was still regularly scoring in like the high 80s or 90s. And so that's the interplay of how all these things come in together, is that we don't have to worry that we can never eat some of those things. It might be that we change the sequence of how we eat them and that we're eating less of these sugary, spiky foods on an empty stomach, which is what 99% of people are doing out there. That's right.

I mean, you just spoke to the complexity of the system. And I think it's so important to realize that, yes, we don't want to demonize foods. We want to learn what's the best way to package them in your system. And that's why I love N of 1 experiments. I mean, it's really the primary tool of precision medicine. And some people are a little daunted kind of hearing, oh, it sounds so sciencey, end of one experiments. But really it's something that all of us do kind of intuitively. We just don't call it that.

So I did an end of one experiment when I was in my 30s and I was struggling with my weight. And I realized, okay, I'm eating too many cookies and ice cream. I've got too many refined carbohydrates. I need to cut back on the carbohydrates that I'm eating. And I need to get into food recovery. And so that was an end of one experiment that really worked for me. And then I've had a similar experience as you where over time, as I've done more weightlifting, I went from being pretty low carb and mostly ketogenic, kind of eaten in and out of ketosis,

to now having more carbohydrates. And it doesn't spike my glucose like it used to. So yes, I eat them kind of at the tail end of a meal. But my glucose disposal, which is really your muscle, Yeah. Has changed. So I've got more lean body mass. I've got, yeah, I just don't get as spiky.

And so with the continuous glucose monitoring, one of the most important things that I think it's done for my health, and I think it's something that others might want to consider, is that it's reversed my pre-diabetes. So I was on this path during my 30s toward type 2 diabetes. no question and no one no doctor that I was seeing was really tracking it or telling me you know you got to do something about this your fasting glucose 105 oh this year your fasting glucose is 110 no one was tracking this for me and so you know there's a lot of ways that um conventional medicine offers us so much for acute care you know if you've got a broken bone if you need your appendix out, I love conventional medicine.

But when it comes to chronic disease, like the way that your metabolism is working or not working, the development of pre-diabetes, the development of type 2 diabetes, it's a place where conventional medicine really falls down on the job. So you've got to track these things. And with continuous glucose monitoring, with doing these NF1 experiments, I was able to reverse my pre-diabetes. And it wasn't just that my fasting glucose was elevating. I went and did some advanced testing with one of my mentors, Mark Houston.

And he demonstrated that with that fasting glucose kind of in the 105 to 110 range, I had downstream consequences to my blood vessels. My blood vessels were showing damage, even though I didn't have diabetes yet. And that's something we see in women, that the cutoffs we use for diabetes, were mostly defined in men. And women at lower glucose in the prediabetes range have more adverse consequences than men do. So it's another really important sex difference. So for the women who are listening to it, I really want you to understand this may or may not be tracked for you.

You really want to take it on yourself. Look at your fasting glucose overtime. Ask for fasting insulin. maybe do a two-hour glucose challenge test. If you can afford it, do some continuous glucose monitoring so that you can see if this is a problem for you. Fantastic. Important reminder. If somebody wanted to go get started on a continuous glucose monitor, do you want to just mention it?

Then we can put your link in the show notes. So I usually advise people to start with their clinician. So the first glucose monitor that I got was as a research subject. and it was a lab that was looking at different food plans and how it affects glucose, so that was about five years ago. But after that, when I saw, you know, I was tracking my pre-diabetes, I went to my primary care doctor, different one than when I was in my 30s, and said, hey, I've got pre-diabetes. I really want to keep this from developing into diabetes.

Could we get a continuous glucose monitor? And my insurance paid for it with the diagnosis of pre-diabetes. So that's not true for all insurance, but I'd say start with your doctor. And if your doctor's unwilling or your insurance won't pay for it, that's when you would consider more a direct-to-consumer approach, but you still need a prescription. So I usually don't recommend just one different direct-to-consumer lab. I usually suggest, you know, Nutrisense, levelshealth.com, there's Zoe Health. There's lots different companies that offer this direct to consumer. That's fantastic.

I want to ask you something, which is that there's been a few people that have come on this podcast and said that cortisol in particular, high cortisol is one of the number one drivers of belly fat in adults. Do you believe that statement to be true? And the context of me asking is that would you say that that is even more of a driver of belly fat and abdominal fat? and maybe contribution to total visceral fat, then even excess calories from ultra-process foods? It's hard to know the relative contribution. I haven't seen that studied. I'm going to put my science hat on here as I answer this. So the data I looked at with cortisol when I did the hormone cure. I found one study that suggested that the fat cells in your belly have more cortisol receptors than fat elsewhere. So it makes sense to me that high cortisol would stimulate

belly fat. And there's a lot of evidence, basic science, as well as clinical evidence, that supports it. So people who have high cortisol, we already talked about how it's associated with depression, It's also a suicide marker. We know that it's associated with a greater risk of developing diabetes, maybe pre-diabetes. I don't know if that's been proven. But knowing that the fat in your belly has more receptors that can be stimulated by high cortisol makes sense as we think about this network effect. The other thing I think about is the role of trauma.

So people who have more adverse childhood experiences when they're, before they're 18. So you can, maybe we could link to an ACE questionnaire. They're free and available online. So it's a questionnaire that just tracks your experience of trauma when you were a kid, things like whether you were neglected, whether you're physically abused or sexually abused, whether your parents got divorced, whether you had someone in your family that was an alcoholic, at alcohol use disorder. So it's a way of measuring adverse childhood experiences.

And people who have more adverse childhood experiences have a greater risk of developing problems with cortisol, and they also have a greater risk of problems with their metabolism and developing type 2 diabetes. So that doesn't get specifically to your question about belly fat or visceral fat, but I do believe there's a link, and I still think we're trying to suss out. some of the details of it. Going back to your sequencing, where you started off with cortisol, and then you talked about thyroid and the importance of that, and you talked about some of the interplay of biodendical hormones, where those can be helpful. We did a little interlude about diet.

Were there other things that you looked at on your journey as you were starting at your own hormonal life in order? There's a lot of things. So if we go back to thyroid for a moment, I found that there were a number of micronutrients that I was missing that hugely affect thyroid function. So I think it might be helpful just to sketch those out. So I mentioned already that my high cortisol was affecting my thyroid. It was affecting the conversion of T4 to T3. So I had low T3, and that's something I see very commonly. In terms of micronutrients, you know, that's something that we take.

to measure in functional medicine. We look at things like vitamin D, copper, zinc, selenium, even iodine. And all of those things can affect your production of thyroid hormone. So you want to be thinking about that. I did my first NutraVal, I think in somewhere around 2005 on myself. And I found that my copper was really low. And when I started taking a multivitamin that had copper, and I also found my vitamin D was low. When I started taking vitamin D and I got my cortisol to come down, it corrected all of my thyroid issues. So it's an example of how you want to be thinking about kind of the bigger ecosystem, including micronutrients and how your body processes some of those. Sometimes it's related to the food quality and the diet that you're eating. But it can also be genetic.

So if you think about genetic drivers related to the thyroid, I have a problem with my vitamin D receptor, so I need higher doses of vitamin D to keep my levels where I want them to be. And vitamin D is kind of like estrogen. It's got like 400 jobs in the body. And you want to make sure that your vitamin D is sufficient, especially for gut function, along with thyroid function. The other piece that I'll mention, and we can go there if you want or not, is that as I corrected my cortisol issues and I got my hormones into a better place, I would reach kind of a new plateau. I would feel really good. I'd have a lot of energy. I would launch another couple of books. And then I would kind of easily backslide. I noticed this pattern over about 10, 12, 15 years.

And I realized that trauma was a big part of the backstory for me in terms of chronic cortisol problems. So I could optimize my cortisol. I could do it with daily meditation and yoga and taking some of these supplements that we've talked about. But I really needed to excavate and reprocess. some of the trauma that I experienced to get my hormones back into balance. So that's not usually where I start with somebody. You know, when we're trying to address hormones, I really start with cortisol. I start with the hormonal Charlie's Angels.

But it's something that you want to be thinking about, especially if you're someone who's been working on your hormones for a while and they get better and then they backslide. They get better and then they backslide. You want to be thinking about trauma. were there tools, methodologies, therapeutics, courses, books that were significant for you to the extent that you feel comfortable to share? Absolutely. Well, I wrote a book about it, so it's about to be very public.

And we're going to, for those that are listening, we're going to have you back on. The book comes out in March of next year, 2024, and we're going to do a whole deep dive on that book. So stay tuned for that. Yes, thank you, Drew. Yeah. So for me, there was a huge shift that came with the early research on MDMA assisted therapy for post-traumatic stress disorder. So I'm someone who's got a pretty high ACE score. My ACE is about six. and basically if you have an A score of one or higher, that's considered elevated. So about 60% of Americans have an elevated A score. And so mine's six.

And it just puts me at risk for 40 plus different chronic conditions, including diabetes, including problems with blood sugar and cortisol issues. For those that are following, that could be anything from growing up in a situation where somebody was impoverished. It could be growing up and living with a parent who had substance abuse. Yes. So there's a whole list of things you check them off and that leads to the totality of the score. And in your instance, you're saying yours was six.

Mine was six. And so as I started to look at this literature, I just was kind of stunned at how effective MDMA is. for resolving trauma. So if you look at the initial studies, the phase two studies, and then the phase three studies, the first study was published, the first phase three study was published in nature in 2021. And what we knew going into that study is that if you've got significant trauma, if you've got post-traumatic stress disorder, so you can think of, you know, maybe depictions that you've seen in movies or on TV, you know, like a veteran who's come. back from the Gulf War, who's got hypervigilance, maybe has nightmares, is reenacting some of

the trauma that he or she experienced. So post-traumatic stress disorder is usually diagnosed by a psychological expert, like a psychiatrist or a psychologist. And when you look at the kind of medical interventions that are FDA approved for post-traumatic stress disorder. Talk therapy as an example. The efficacy for resolving PTSD is on the order of about 30%. That's pretty abysmal. Not great. It's not great. So for someone who's got trauma, who's been in therapy for like decades, and we all know that it costs a lot and it's slow and it takes a long time, if I knew that it was 30% effective, I don't know that I would have done it. And then if you look at some of the medications that are FDA-approved for PTSD, some of the selective serotonin re-uptake inhibitors, they have

an efficacy of about 30%. So this is what a lot of veterans are being offered. Some of them are getting trauma-informed care. Fortunately, we're getting better at this. But if you look at MDMA-assisted therapy in someone with post-traumatic stress disorder, the resolution of PTSD is on the order of about 67 to 71 percent, so more than double what is currently FDA approved. So when I saw that, it got me really interested, and I felt like if there are some behaviors that I have that are showing up as this chronic cortisol problem, and I have the opportunity to resolve them with MDMA-assisted therapy, I'm going to do it. So I think the promise of psychedelic assisted therapy is really enormous.

And my hope is that MDMA becomes the first FDA-approved treatment for trauma for post-traumatic stress disorder. And keep in mind here, you know, for our listeners, you may not have post-traumatic stress disorder or maybe do, and you want to pay attention to this. but there are a lot of people running around who are more like me who have what I think of as partial PTSD or the medical term for it is subthreshold PTSD. And we can be super functional, but we may not be able to really serve our mission in the biggest way possible because of this trauma that's still lurking in our system.

So that's the thing that probably got me the most excited in terms of how you can rebalance the endocrine system to consider some of these novel therapies like psychedelic-assisted treatment. What did you notice in your body after going through whether it was your first or a series of these treatments? I'm so glad you asked that question because it's really. that that's the main question with trauma because people who've experienced trauma often are not at home in their body. And so you asking, what did you notice in your body? What I noticed immediately with the first MDMA assist therapy that I tried was that I was back in my body the entire time that I was on the medication. And it was durable. And I realized how much I dissociated as a way of coping with a trauma, as a way of coping with, you know, a career

choice that exposes me to a lot of trauma. And I think this is something that a lot of people may do as well. I would dissociate to a cognitive processing place where if I was feeling stressed, I would just immediately go upstairs to my brain and just try to problem. solve. And it was a form of dissociation where I would just feel like I was up here and everything kind of below the neck, I would just ignore. And medicine in many ways selects for that, right? I mean, Gabor Mata talks about this, about how you go into medicine, they give you this weird uniform, right? You start wearing scrubs all the time. They isolate you from your family. You're like in the hospital. I was working 120 hours a week.

It's almost like a cult, and it sort of selects for this dissociation, so that you are in the emergency room, a car accident comes in, and you're able to just go cognitive and, like, go through this process of doing everything that needs to happen. But when it comes to living your life and really feeling what's happening in your body, the emotions that are happening, you can become kind of a nerd to it, you can become dissociated. So it got me really interested in in, okay, how do we actually get embodied again? Because that's what I felt with these medicines. I felt embodied again, Drew.

That's powerful. On a day-to-day level, did you also notice, no matter how small, I mean, first of all, being embodied, being back in your body is so big. For anybody that has not had that. On a day-to-level, did you notice shifts in your health that would show up as a byproduct of being back in your body? Yeah, it's such a good question.

And as I was, you know, I was first prompted by all these patients that were coming to me with autoimmune disease. And then I started to do ACE questionnaires on all of my patients. And I noticed that the ACE scores were higher in the people that I had with autoimmune disease. And that's what got me to kind of look at this process and look under the hood. Like, why is this happening? And I realized, okay, the system that gets disrupted by trauma is the pine system, your psycho, immunoneuroendocrine system. And for some people, it might just be one of those four. Maybe their psychological system gets disrupted. They've got depression, anxiety, post-traumatic stress disorder. But usually it's more than one system that gets disrupted.

and there are some who have this vulnerability with their immune system, and their immune system becomes overactivated, and that's oversimplified, but that leads to autoimmune disease. And we know that for most autoimmune disease, you have to have this combination of genetic predisposition, together with increased intestinal permeability, and then a trigger, and sometimes that trigger is trauma. So I can't remember what your original question was.

but I was asking did you notice, you know, immediately there was a shift being back in your body. Yeah. Did you notice any areas of your health? Oh, yeah. That you would have said had improved, which already being in your body, and I'm sure if there was some history of sort of HRV scoring that you had, you'd immediately have seen a major shift in sort of background stress that was there. Yeah. Like, did you notice that you were, you know, holding your breath less often? That's something that I've heard from individuals that have gone through MDMA-assisted therapy,

that they're not always bracing for some sort of impact. Because their body was used to doing that as a survival mechanism of the trauma that they went through. So no matter how to big or small, and it's okay if there wasn't anything else there. No, there's a ton. There's a ton. Thank you for redirecting me. I noticed so many things when I started trying these therapies, and I did it, you know, in the context of having experts guide me through. And, you know, we have to be a little bit careful about what's legal.

There's some differences state by state. The one psychedelic and some even debate whether it is a psychedelic that is legal is ketamine. So if we take ketamine for a moment, I did ketamine-assisted treatment. And I also, you know, I'm a nerd. And so I would wear my continuous glucose monitor. I would look at my aura ring. I would kind of see what happens, pre-post these treatments. And what I found with ketamine, for instance, is that my heart rate variability would double after I did a ketamine session.

So I'd look at it for a week before and then I'd look at it for a week afterwards and my HRV would double. My sleep was better. My deep sleep was better. And I'm not saying that's going to be true for everyone, but for my end of one experiments, that's what I found. So I find it super regulating. There are other people.

I think you've talked about this as well, that there are people who notice that, oh, I'm breathing more deeply. I'm noticing the sense of calm. I'm tuning into the signals of my body in a different way. Maybe I'm talking more slowly. Maybe I'm pausing and I'm listening more. So I think there's so many different things that you can track. What I found with my HRV was that it just felt so good in my body.

You know, it's not that I'm like, yay, my HRV doubled. It's more, oh my gosh, I just noticed I felt so much more regulated. I felt like, you know, that feeling I have when I do meditation or a 90-minute yoga class, I felt it more of the time. And so I think we're really at a time in history where we need this. We really need it. You know, on the topic of needing this, and you're so. on the forefront of this, and I'm so excited about your book that's going to be coming out next year.

To contextualize it for the conversation today, do you feel that there's something in particular about these tools being available now for women, if we talk about a cohort of 50 plus, with that demographic of individuals, if we think about the time that they grew up in, the tools that weren't available to them, the conversations that weren't happening at the time, and how much of the burden of often many of those women would have raised families, and so much sacrifice was placed on their plate,

the sacrificing of their health. It seems like a really powerful time period in our society that these tools are now being available for especially that, demographic of women. Any thoughts on that? Well, it's making me misty as you talk about this. You know, as someone who has served women for the past 30 years,

I would say there's nothing more promising than healing states of consciousness of which psychedelic assisted therapy is one part. And you're right. I mean, what I feel personally is that I'm not just kind of selfishly going in and excavating and resolving my own trauma.

I feel that I'm actually going to past generations and healing some of those epigenetic changes that were passed on to me. And so when you call out women, especially women that are in this age group, you know, kind of the 35 to 55, 65, 65 age group. There is so much promise here for, you know, the struggle with patriarchy, the struggle with sacrifice, the struggle with glass ceilings, the struggle with how women disappear over the age of 40, and just become dismissed and don't feel as relevant as they once were. So we have to do everything within our power to help women be the fullest expression of themselves. And I really believe that healing states of consciousness can do that true.

So there's so many different ways to do that. You know, certainly yoga and meditation, holotropic breathwork, which is something I've done for the past two years. There's so many different ways to access these healing states of consciousness. Someone might do Qigong or Tai Chi or some other contemplative practice. I would say psychedelic-assisted treatment, my understanding of the science and also my personal experience, and the three certifications that I've done professionally, has shown me that there is more promise here than I've seen with any other intervention in my 30 years. of taking care of patients. A super hopeful and promising message about what's available to everyone,

men, women, everybody, people in different countries. Maybe if the entire world had access to this one day, the world would just be a little bit more of a loving place if we can learn how to love ourselves a little bit more. That's what I would hope. That's what I would hope. And, you know, the,

One of the things that you reminded me of is when we look at soul wounds, we look at epigenetic change that gets passed on, you know, from, for instance, my great-grandmother to my grandmother, to my mother, to me, what we know from quite rigorous scientific studies is that the genes that tend to get the paper clips put on them, that tend to get changed in terms of their expression. are genes of metabolism and genes of the immune system. Those are the ones that change the most. And so we want to be thinking about, okay, what do we have at our disposal to work with some of these epigenetic changes? And that's part of why I think psychedelic-assisted medicine or more generally healing states of consciousness are so promising. But they also have to be superimposed on all of these lifestyle changes. that we've been talking about. Yeah.

So it's not either or. Yes, it's the two together. Dr. Godfrey, this has been fantastic. And I was hoping that as we wind down here, you might be open for a little bit of a recap in a way of some of the key sort of themes that we talked about. And I think that one of the first ones that I'd love to start off with and feel free to get on your soapbox and take us through the rest

or I'm happy to guide you through them is just this, core idea that it doesn't have to be this way. Can you start there? Yeah, you know, I, when I think back to how much I struggled when I was in my 30s and I just, Drew, I felt like I was pushing a rock up the hill and I was just like, why is this so hard? Like, why I'm too young to feel like this is so difficult? And I was missing this piece about how hormones, drive what you're interested in. Hormones really drive what you're excited about. They are such an important signaling molecule in your body. And even though some of the things we've talked about today might seem daunting or seem like a lot to do, it's easier to get your hormones back

into balance than to live in that state of hormonal misery. So I think that's a really critical place to recap. Everything is hard, but one hard has the pathway of feeling better. Yes. So choose your hard. That's right. Could you share a little bit of a recap on your top lifestyle interventions that you feel are crucial if somebody wants to feel better, especially when it comes to this category of hormones? Well, I would say for this group that we're talking about, so women who are,

in pari menopause and menopause. I would say the top lifestyle interventions are number one food, food first. So really getting clear about end of one experiments, doing some of the things that we've talked about, eat more vegetables, make sure that you're getting adequate protein so that you're maintaining or maybe even growing your lean body mass, eating in a way that supports your hormones. Number two is managing cortisol because it's not a democracy. So cortisol is so critical. Insulin's critical too, but start with cortisol. Get cortisol supporting you instead of working against you.

And there's so many ways to do that. We talked about things like yoga and meditation, supplements like phosphatididyl serine, rhodiola. So you might want to measure your cortisol and then develop a plan to address it. And then I think it's important to look at thyroid because women in this age group are at risk of thyrapause. You really want to know what's going on with your thyroid. So track your panels. And then estrogen is the primary regulator.

It's dance with progesterone you really want to pay attention to. And we also talked about testosterone because I think testosterone is the most important. the most testosterone is the most abundant hormone. And so we want to make sure that it's in that Goldilocks position, not too high and not too low. And there's so many lifestyle things that you can do to address that. Things like reducing refined carbohydrates, cutting sugar out of your diet and ultra-processed foods, getting adequate protein and strength training. Fantastic. Those are all available and largely The vast majority of those are either things that people are doing, so we're just shifting habits.

And if you're not doing them, a lot of them are either low cost or free interventions that you could do. Like sleeping on a regular time to try to improve your sleep quality, you know, lowering your stress level through things like meditation. There's plenty of guidance on YouTube and other things that are available that are out there. So I love that. It's the reminder for everybody here that all of these tools, are available and you can set up, it reminds me of this quote from the financial author Dave Ramsey. He says, you know, if being broke is normal, then be wealthy, which is weird. So be a little weird. And when it comes to your health, the same thing is true. Be a little weird. Be in your

optimal. Feel good. Be a different version. of aging that's out there to a degree that people are asking you, what do you do? And all of a sudden, you're an example and a catalyst for change. Thank you again for being on the podcast. I think this is your third appearance. My favorite appearance because it was in person. And I feel like it's a whole different conversation

that's there. For those that are listening today and want to go deeper down the rabbit hole of Dr. Sarah Godfried, how can they keep in touch with you? And where should they start when it comes your books? I'd recommend starting with the hormone cure. That's really the kind of the original, and it lays the foundation for the functional medicine paradigm that I use when it comes to hormone balancing. You can also go to Sarah Gophradmd.com. That's where I publish blogs,

and I have a lot of information about my new book, for instance. And the social media, where I hang out the most is Instagram. As you know, I love watching your stuff over there, Drew. So that's probably the best place to have a conversation. Fantastic. Well, we'll have links to all those in the show notes. Dr. Sarah Gottfried, thank you again for being the voice of women who are looking for a different way to go about things.

It's been an honor to host you on the podcast today. Thank you, Drew. Hi, everyone. Drew here. Two quick things. Number one, thank you so much for listening to this podcast. If you haven't already subscribed, just hit the subscribe button on your favorite podcast app. And by the way, if you love this episode, it would mean the world to me.

And it's the number one thing that you can do to support this podcast is share with a friend. Share with a friend who would benefit from listening. Number two, before I go, I just had to tell you about something that I've been working on that I'm super excited about. It's my weekly newsletter. And it's called Try This. Every Friday, yes, every Friday, 52 weeks a year, I send out an easy. easy-to-digest protocol of simple steps that you or anyone you love can follow to optimize your own health. We cover everything from nutrition to mindset to metabolic health, sleep,

community, longevity, and so much more. If you want to get on this email list, which is, by the way, free and get my weekly step-by-step protocols for whole-body health and optimization, click the link in the show notes that's called Try This or just go to drewproet.com. That's d hr u p u r o hit dot com and click on the tab that says try this