Huberman Lab - Essentials: How to Optimize Female Hormone Health for Vitality & Longevity | Dr. Sara Gottfried

Episode Date: August 13, 2026

In this Huberman Lab Essentials episode, my guest is Dr. Sara Gottfried, M.D., a Harvard-trained, board-certified gynecologist and expert in female hormone health. We discuss the key biomarkers women should track at each stage of life and how cortisol, thyroid hormone, estrogen, progesterone, and testosterone shape energy, mood, metabolism, and long-term disease risk. We also discuss PCOS, the risks and benefits of oral contraceptives, and the shift in brain metabolism that begins in perimenopause. Dr. Gottfried explains actionable tools for hormone and micronutrient testing, nutrition, stress management, and cardiometabolic screening that women can use at any age. Read the episode show notes at hubermanlab.com. Thank you to our sponsors AG1: https://drinkag1.com/huberman LMNT: https://drinklmnt.com/huberman Eight Sleep: https://eightsleep.com/huberman Timestamps (00:00:00) Female Hormone Health (00:00:24) Family History, Intergenerational Trauma; Endometriosis, Fibroids, PCOS (00:01:31) Biomarkers by Decade; Teens & Cortisol; 20s & Sex Hormones (00:03:35) Tool: Hormone Test Timing; Micronutrient Testing, Magnesium (00:05:41) Sponsor: LMNT (00:07:17) Tool: Smoothies, Greens Powders & Microbiome (00:08:12) Nutrient Panels, Antioxidants, B Vitamins, Glutathione (00:09:34) Constipation, Thyroid Dysfunction; Trauma & Female Physiology (00:11:50) Tools: Reduce Perceived Stress, Meditation, Yoga, Breathwork (00:13:30) Opportunities by Decade; Androgens & Testosterone Decline (00:14:50) PCOS, Diagnostic Criteria, Hirsutism, Cardiometabolic Risk (00:17:10) Insulin & Glucose; Tool: Continuous Glucose Monitors (00:18:05) Democratizing Health Data (00:18:52) Sponsor: AG1 (00:20:07) Longevity "Don’ts"; Chronic Cardio & Cortisol; Tool: Adaptive Exercise (00:22:46) Oral Contraceptives, Benefits & Ovarian Cancer Risk (00:24:27) Ovarian Cancer Symptoms, Bloating, CA-125 (00:25:51) Oral Contraceptive Risks, Progestins, Inflammation; SHBG & Testosterone (00:29:08) Clitoral Shrinkage; Tools: Alternatives for Painful Periods (00:30:14) Sponsor: Eight Sleep (00:31:32) Menopause & Perimenopause; 30s Hormonal Baseline (00:33:07) Female Brain, Cerebral Hypometabolism & Alzheimer’s Risk (00:35:02) Slow Brain Energy, Hormone Therapy; Hot Flashes as Biomarkers (00:36:54) Tool: Coronary Artery Calcium Score Disclaimer & Disclosures Learn more about your ad choices. Visit megaphone.fm/adchoices

Welcome to Huberman Lab Essentials, where we revisit past episodes for the most potent and actionable science-based tools for mental health, physical health, and performance. I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine. And now for my discussion with Dr. Sarah Gottfried. Dr. Gottfried, Sarah, welcome. Thank you. So happy to be here. Yeah, I'm delighted and very excited to ask you about an enormous number of topics. You are expert in so many things. female hormones in particular. Is it ever informative for a woman, regardless of age, to know something about her mother's, perhaps even her grandmother's experience vis-a-vis hormones?

What sorts of conversations should women be having with themselves and with family members to get a window into what their specific needs might be? So my work is really at the interface between genetics and empowerment. And I think it's essential that you understand what you're, grandmother went through, and especially your mother. So I would probably start first with trauma, an intergenerational trauma, because I think that affects the endocrine system so hugely, especially cortisol signaling. And then there's certain female conditions that have a very strong component genetically, most of which run in my family. So that includes endometriosis,

fibroids and polycystic ovarian syndrome. Maybe we could march through and just say for a woman in her teens who's already hit puberty, what sorts of biomarkers should those young women be paying attention to? Likewise for women in their 20s, 30s, maybe we could take it more or less by decade, starting at puberty. In your teenage years, what I think is really interesting is to look at cortisol. To look at the dance between estrogen and progesterone in those years is less helpful because I think there's a lot of variability due to the immaturity of the system. If you've got someone who's got really regular periods, it's probably better to do some benchmarking at that age.

But generally, I find that benchmarking is best performed in your 20s or 30s. Are periods not that regular in terms of duration of the menstrual cycle when the menstrual cycle first sets in? For a lot of women, they're not regular. And then there's the whole piece of oral contraceptives and other forms of contraception, where you have no idea what the normal cycle is. But getting back to your original question, which is about biomarkers per decade, in your 20s, that's when you want to do some base casing with estrogen, progesterone, and testosterone.

What happens a lot of the time is that estrogen dominates in that tango. And when that happens, it sets you up for greater risk of fibroids, endometriosis. I'd want to know about DHEA and sort of the whole androgen pathway. I'd want to know about the metabolites of estrogen because some of them are protective and very helpful. Others are a bit like Homer Simpson. I mean, they are just like causing all kinds of problems in your body. I'd also like to know about their stool. So I want to know about the microbiome.

In terms of blood testing or various tests for these other biomarkers getting estrogen, testosterone, and other ratios. Women will need to do it at different stages of their menstrual cycle. If they had to pick one, either in the follicular phase or in the ludial stage of their ovulatory menstrual cycle, when would you suggest they do that? So if you force me to pick one, I would say probably day 21 to 22 for someone in her 20s. So for most women, they've got a menstrual cycle date that averages out at 28 days. So this is about a week before they start their period. For women or more irregular, it's harder to do that. As women get older, usually the cycle gets a little shorter.

So as they start to decline in their progesterone production, their period gets a little closer together. At that point, you want to test sooner, like day 19, 20. Blood test is the cheapest thing. It's usually what's covered by insurance. But my preference would be to do dried urine so that I get metabolomics in addition to the levels of these hormones. And if I'm forced to, I'll use blood testing.

it's not as comprehensive. And as you know, it's a quick little snapshot while the needles in your vein for, you know, 30 seconds. Let me go back and say one other thing about biomarkers. A big part of the testing that I do in phenotyping my patients, I practice precision medicine. I like to almost start with nutritional testing. That would be potentially a helpful thing to do in your 20s.

It becomes less important as you get older and you develop more micronutrient deficiencies. But micronutrients play a huge role in terms of hormone production. Magnesium is hugely involved in the way that you get rid of estrogen, as an example. So micronutrient testing, what I usually do is a combination of blood and urine. And so I'm looking at all of the micronutrients that we can measure that have some clinical scientific basis behind them. Intake of vegetables, polyphenols, is such an important predictor of future risk of breast cancer, like when you're 50, 60 plus. And the most important time is when you're a T.E.

teenager. If you have evidence that you could show a 17-year-old that they've got micronutrient gaps, I think that would be a motivator for them to eat differently at a time when it's so critical, even though it's 25 years in the future that it's going to potentially change this arc that they're on. I'd like to take a quick break and acknowledge one of our sponsors, Element. Element is an electrolyte drink that has everything you need and nothing you don't. That means the electrolytes, sodium, magnesium, and potassium in the correct amounts, but no sugar. Proper hydration is critical for optimal brain and body function. Even a slight degree of dehydration can diminish cognitive and physical performance.

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I love the raspberry. I love the citrus flavor. Right now, Element has a limited edition lemonade flavor that is absolutely delicious. I hate to say that I love one more than all the others, but this lemonade flavor is right up there with my favorite other one, which is raspberry or watermelon. Again, I can't pick just one flavor. I love them all.

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I mean, we know that makes a difference in terms of microbiome change. Like I have them do steam broccoli that's in the freezer because it's got very little taste. They could do that in a chocolate smoothie. They could add some greens. I like greens. Powders are super convenient. So that with, you know, kind of a taste that they like, whether that's chocolate, which is what most of my clients want, or, you know, vanilla with berries and that sort of thing. So that can go a long way if you don't like vegetables.

And short of that, I would say some supplements, but I would say that's a distant second to making a sense. smoothie. What is going to be the best way to test the microbiome? What I like to do with nutritional testing is run a panel that's looking at antioxidants, so like vitamin A, vitamin C, alpha lipoic acid, plant-based antioxidants, because you can measure that in the blood. I like to look at some of the key vitamins, especially the B vitamin range, because as you probably know, if you've got a particular genetic polymorphism, Steve might be less likely to be absorbing the right level of vitamin B9, folate, vitamin B12, et cetera. I'm also looking, going back to the antioxidants at glutathione, because I think that's such an important lever. And then I'm looking at some of the minerals.

Magnesium is really the most important. And we know that somewhere around 70 to 8% of Americans are deficient in magnesium. That's like the lowest hanging fruit. I would be curious, for instance, Like with magnesium, if that number of people are deficient, does that mean that that number of people should be targeting their nutrition towards foods that contain magnesium and or supplementing with magnesium? And if so, what forms of magnesium? You have to measure red blood cell magnesium, like whole blood. And with deficiency, it's interesting with supplementation for my patients who tend toward

constipation, and that's frankly about 80% of the women that I take care of. Really? Yes. Wow. I'd be curious as to why that is. Patriarchy, rage, the pine system. Right. Psychology, immunology, neural and endocrine factors combined.

Is that? Yes. And then I would say there's another factor. Being female is a health hazard. So we have twice the rate of depression, insomnia. We've got three to four X increased risk of multiple sclerosis. We've got five to eight times the risk of thyroid. dysfunction. So if you just look at that and you look at subtle preclinical thyroid dysfunction,

a large number of the women that I take care of have thyroid dysfunction that's contributing to constipation. And if we go back to that control system, the hypothalamic pituitary adrenal thyroid genital gut access, and they have a lot of perceived stress together with this borderline thyroid function that no mainstream medicine doctor has told her is a problem. And then she's got a problem with the tango between estrogen and progesterone. She's going to tend toward constipation. Women have a lot more constipation than men. The gut is about 10 feet longer in women compared to men. And they are much more likely to have a torturous colon. And the way you know that is you get a colonoscopy. Women experience more trauma than men. This is well established. If you look at the

ACE studies that were done by the CDC and Kaiser in 1998, we know that men for the most part, middle-aged men have about, about 50% of them experience significant trauma as defined by the ACE questionnaire. Women are at 60%. And that's pretty durable since 1998. They have different forms of abuse, much more likely to have sexual abuse. They have a different HPA response than men. Their perceived stress tends to be higher, and I'm generalizing for a population.

And so if you look at the physiology of a female, I think that constipation and that need to like control and restrain and hold things in, I think that's part of the physiology. So I'm veering away from the science, but I do think that it is a really important signal to pay a lot of attention to. What sorts of tools do you recommend people use to relieve constipation? Sounds like reducing stress is going to be a huge one. Yes. What are your favorite stress reduction tools, things that can really really.

lower the baseline. So I'm not a fan of lowering stress. I'm a fan of lowering perceived stress. I think all of us need an a cart menu of what is most effective. So what works for me now at my age is different than the TM I did as a college student, transcendental meditation. I became a certified yoga teacher when I was in my 30s. That is very effective for a lot of people. I do holotropic breath work. I think people are starting to appreciate that there are ways that they can relieve their stress that don't only fall under the categories of vacation and meditation. But I want to say that meditation is obviously a wonderful tool. Well, certainly it's a great tool and it's got such a scientific basis behind it. But there's so many things on this all-a-carb menu.

Sex, orgasm, connection, feeling heard and seen and loved. I want to use this as an opportunity to, A, keep this in mind. as we turn to a question that I didn't close the hatch on earlier, and it's my fault, which is I'm now clear on the fact that a woman in her late teens, early 20s, ought to know something about her testosterone, estrogen, thyroid, cortisol levels, should start at least thinking about her microbiome, should be thinking about how many bowel movements and the timing of those bowel movements per day. And I'm assuming that what I just described is also true for women in their 20s, 30s, 40s, 50s, on up to whole.

hundreds. Is that correct? That's correct, but I would say that there are differential opportunities by decade. So I'm glad she's circled it back to teenagers and testosterone, because I think if you know, for instance, in your teenage years that you have high androgens and that you've got this potential phenotype way into the future that you may not even notice. I mean, maybe you notice you've got a few extra hairs on your chin or something. If you know that your testosterone is elevated or some other androgen, it might change the arc of how you take care of yourself. So I think that could be very helpful in your teenage years.

In your 20s, for people who are a stress case like me, so age 27 on the wards at UCSF, if I had known that I was such a high cortisol person, I think I would have done things differently. I would have changed my behavior. your testosterone can decline starting in your 20s, kind of depending on how much stress your matrix is under. So for women, that can start as early as 28, usually your testosterone declines by about 1% per year.

What level of testosterone do you like to see in a woman once she's sort of post, let's say after age 25? So the way I tend to describe this on podcasts is the top half of the normal range. I get a lot of questions about PCOS. Yeah. So PCOS is, one of those really poorly understood conditions. It kind of flies below the radar until a woman wants to get pregnant or she's got some other issue that drives her to a physician. The problem is

that it is a syndrome, right? So polycystic ovary syndrome, sometimes polycystic ovarian syndrome. And syndromes don't necessarily fit together into a really clear diagnostic criteria. So in this instance, There are three different criteria that we look for. So, cysts on the ovaries, having clinical manifestations of hyperandrogenism. So that could be hercetism, acne, other things. And then usually irregular periods. And the way that that's defined, at least by the latest criteria, is having a period every 35 days or less. So typical cycle length, 28 days, 35 days.

You know, you're skipping a period here and there. So those are the criteria that we use to diagnose PCOS. there are about four different systems out there in the literature for diagnosing PCOS, which is where it starts to get confusing. So there's some women who have nois on their ovaries, but they've got heercitism and they've got irregular periods. Could you define haircitism? Hercetitism is increased hair growth, usually in places that you don't want it. So for women, it can be kind of male pattern. They might notice it on their breasts, on their chest.

What we know is that PCOS is not just a problem in terms of irregular periods and then difficulty getting pregnant. So those are mostly problems in your 20s, 30s, early 40s, but it is a massive risk factor for cardiometabolic disease as you get older. So many people tend to pigeonhole PCOS is a problem of reproductive age. We have to be thinking of it over the entire female life cycle. And I would say it's even more important to consider it over the age of 50, you know, average age of menopause is 51 to 52 because we know that that elevated testosterone, the high androgens, are probably the greatest cardiometabolic driver of disease for women with PCS. The thread we haven't talked about is the role of insulin and glucose. So for some of the phenotympic

of the phenotypes of PCOS. The problem is hyper insulinemia, high insulin in the blood, is driving those thika cells in the ovaries to overproduce testosterone. Are you a fan of continuous glucose monitors? The hugest, most gigantic fan of CGMs. I've never seen any tool that I've ever used in medicine change behavior the way that CGMs do. Like I think really understanding what the mediators are of your glucose control is essential. Now that said, it's also kind of a later effect. I mean, I'd rather know your insulin. And we know from the White Hull study that insulin, especially post-prehandial insulin, fasting insulin too, can change years and years before you get

a change in glucose. So that's more for pre-diabetes and diabetes. Third thing is it democratizes data. One of the most hopeful and exciting things that I'm seeing right now in the health space, is that we're going from this patriarchal relationship where doctors hold the power and are the gatekeepers of data to patients and clients having much more access to that enchantment about their own chemistry and their own biology. Teaching the patient to be their own clinician, to me that is a loop of benevolence and integrity that I think is essential to, to creating health. We've got a disease care system. We need the democratization of data to become a health-based system. I'd like to take a quick break and acknowledge our sponsor, AG1. I'm excited to share that AG1 has just launched their newest formulation, AG1 Pro. Ag1 Pro takes the clinically backed AG1 formula, which is a blend of vitamins, minerals, probiotics, and

adaptogens, and adds three important new ingredients, creatine monohydrate, calcium, HMB, and zinc carnacine. Each serving has five grams of creatine monohydrate to support muscle strength and performance as well as brain health. Calcium HMB to support muscle recovery and reduce muscle breakdown and zinc carnacine to support and improve the lining of your gut. All three of these ingredients have compelling science to support them, and therefore I love seeing them added to the existing AG1 formula. As most of you know, I've been taking AG1 every day for nearly 14 years now. I started taking it long before I even knew what a podcast was. It's a great product and it's now made even better with the new AG1 Pro formula. If you would like to try AG1 Pro, you can go to drinkag1.com

slash Huberman to get a special offer. Ag1 is giving away a free bottle of omega-3 co-enzyme Q10 with your first subscription. Again, go to drinkag1.com slash Huberman to get a free bottle of omega-3 co-enzyme Q10 with your first AG1 subscription. If you add a magic wand and you could give two or three don'ts to maximize vitality. and longevity. Let's focus first on female patients, but if it extends to male patients as well, what would you like to see them not do? So I would say sleep, alcohol, high perceived stress, eating the wrong foods, toxic relationships

and isolation. And then number six, not moving enough or not moving and exercising in a way that really fits with your body. Can we start with that one actually? Sure. Because it's such a and then work backwards. Yeah. Well, I think for me, because I have a phenotype.

that produces a lot of insulin, kind of depending on how I'm on my game. I have a lot of glucose. So I have to exercise a lot more to dispose that glucose. So I think you then have to move from medicine for the population or prescriptions for the population to what works for the individual. One of the mediators that I think is important, especially for people who do what I call chronic cardio, which is what I did, is cortisol. So we know that runners, especially marathon runners, people who do a lot of cardio and don't do much resistance training, they tend to have much high cortisol levels. And you can buffer that with vitamin C. Vitamin C can decrease the effect. But chronic cardio doesn't always serve people. When I first started measuring hormone panels in myself, I went to my physician and I said, I'm 35. I've never been so exhausted in my life.

I just feel like I'm pushing a rock up the hill. I've got this belly fat that I don't like. And I don't want to have sex with my husband. What could we do about this? And he offered a birth control pill and an antidepressant. Oh, goodness. So I left him and I went to the lab and I ran a hormone panel and my cortisol was three times what it should have been. My insulin was in the 20s.

I was fasting. My glucose was 105. My thyroid was mildly abnormal. My progesterone was low. And that set me on this course of realizing that what I was doing as a physician, taking care, especially of women, was not getting to some of these root causes that are so essential. And I would say I had to start first with cortisol. At that time, I was running four miles, three times a week, four times a week. That was just racing my cortisol further.

So that was not the right exercise for me. I needed more adaptive exercise. I started doing Pilates, more yoga. That helped to lower my cortisol. I mean, it started me on changing the way I was managing perceived stress, and it also changed my supplement regimen. I'd like to make sure that we circle back to birth control. In particular, oral contraceptive birth control.

What are your concerns? What do you like about oral contraceptives? What do you dislike about them? In terms of benefit, I think that, especially when they first came out and even now, it gives women reproductive choice, and that's essential. So I'm a big fan in that regard, and we've got a lot of data to show both the risks and also the benefits of it. So I'll speak first into the benefits because I'm going to get on a soap box a little bit about the risks.

So we know that it reduces the risk of ovarian cancer. So there's something about this idea of incessant ovulation that is not good for the female body. So if you look at, for instance, women who are nuns who don't take oral contraceptives and they have a period every single month of their reproductive lives, they have a greater risk of an veteran cancer. So if you look then at women who have several babies and they've got a period of time when they're pregnant that they're not ovulating and then they breastfeed for some period of time, they have a lower risk of an avaring cancer. So oral contraceptives help with reducing ovulation and reducing risk. We know that if you take the oral contraceptive for about five years, it reduced your risk of ovarian cancer by 50%. And that's significant because we're so poor at diagnosing ovarian cancer early. There's really no method that's really effective.

We use CA125 and ultrasound screening, especially in women who are at greater genetic risk. But even that, often we diagnose it, you know, in a later stage. Maybe just because that statement is going to highlight for a number of people, the question of what are some of the earliest symptoms that people can recognize without a blood test. So is ovarian cancer, is it going to be pain? So the problem is the symptoms are so vague and they're so nonspecific. One of the most common symptoms is bloating. And we've already talked about constipation.

We've talked about how women have this longer track. eye track. And so bloating is a really common experience for most women. You can have bulk symptoms, you know, feeling like your lower belly is kind of pressed out. The way that we inform women in terms of watching for this is to get regular gyneclicic exams for women who are at high risk where they have, for instance, an ultrasound for some reason and it shows a mass that we're concerned about. There's a way to triage that in terms of what kind of evaluation that they need. And that's a situation where you might get a blood test called the CA-125. Taking estrogen and thereby reducing the frequency of ovulation lowers the risk of ovarian cancer. Should women that are, even women who are

not sexually active, so they're not actively trying to get pregnant or avoid getting pregnant, but if they're not sexually active, would they be wise to suppress ovulation for periodically using hormone-based contraception just so that they can offset the risk of ovarian cancer? That's a very rational question, and I would say that's what mainstream medicine has had at its back to recommend oral contraceptives, not just for women who are seeking contraception, but for acne, for painful periods, for really kind of the drop of a hat, they're prescribing oral contraceptives. That's what I was taught to do. And I think a lot of that is pharmaceutical influence. The oral contraceptive is two hormones. It's ethanol estradial, and it's a progestin. So it's not the normal progesterone that your body makes, that your ovaries make, and your adrenals make. It is a synthetic form of progesterone. And it is the same progestin, similar, same class that was shown to be dangerous and provocative in the Women's Health Initiative. So I'm not a fan of progestins. I do not recommend them for any woman unless it gives them some freedom in some way.

So like with almost any pharmaceutical, the oral contraceptive depletes certain micronutrients. Magnesium, there's certain vitamin Bs that are depleted. It also affects the microbiome. That data is not as strong, but there seems to be some effect, and there's also an increased risk of inflammatory bowel disease in autoimmune condition. It increases inflammatory tone. So the studies that I've seen increase one of the markers of inflammatory tone, high sensitivity CRP by about 2 to 3x. It seems to make the hypothalamic pituitary adrenal axis more rigid

so that you can't kind of roll with the punches and wax and wane in terms of cortisol production the way that you can off the birth control pill. It can infect thyroid function. Anytime you take oral estrogen, it raises sex hormone binding globulin. And you've talked to other podcast guests about this, Kyle, I think. sex hormone binding globulin, I think of as a sponge that soaks up free estrogen and free testosterone. So when you go on the birth control bill, you raise your sex hormone binding globulin. It soaks up especially free testosterone.

And for some women, it's not a big deal. They don't notice much of a difference. But then there's a phenotype, maybe related to CAG repeats on the androgen receptor, who are exquisitely sensitive to that decline in free testosterone. So this then opens the portal of talking a little bit about testosterone and women. It's the most abundant, biologically, the most abundant hormone in the female system. It is so important for women. It is essential to so many things, not just sex drive and muscle mass and seeing a response to resistance training,

but also confidence in agency. And so those women who are, are so sensitive to their testosterone level, they've got this high sex hormone binding globulin, their testosterone declines. What they describe is vaginal dryness, maybe a decline in sex drive, but there's also this bigger issue related to confidence in agency, even risk-taking from studies that we've done with MBA students that I think is a serious problem. Maybe the most important out of all of these things, is that it can shrink the clitoris by up to 20%. 20%. And if I've got a woman that I think should not be on the birth control pill, maybe she's

taking it for acne or she's taking it because her periods were a little painful. What I'm going to do is say, let's leverage these other ways of making your period less painful. Let's take the message of your painful periods and figure out, okay, it's your inflammatory tone. And we give you some fish oil and SPMs, maybe a little aspirin when you've got your period. Like, let's find some other ways to deal with it than to take the oral contraceptive, which you have not received informed consent about because it can trick your clit by up to 20%. Now, that usually convinces most people to come off of it. The data that we have is limited. There's one woman who, Claudia something something, who looked at sex hormone binding globulin a year out from stopping the birth control pill,

and it was still elevated. It wasn't as high as it was when they were on the pill, but it was still elevated. So your question about reversibility, I don't know if we know the answer to that. I'd like to take a quick break and acknowledge our sponsor, 8Sleep. Eight Sleep makes smart mattress covers

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So in your 30s, having a base case, I think is really essential. What's more interesting is to talk about perimenopause. So perimenopause is the period of time before your final menstrual cycle. And for most women, depending on how attuned you are to the symptoms, it can last for 10 years. So I'm still in period menopause. it's been like 20 years because I've been tracking it so carefully. It usually gets kicked off by having your cycle get closer together. So that can happen in your 30s or your 40s. You go from 28 days to 25 days, that sort of thing. You may notice it as more anxiety, difficulty is sleeping, and that

probably is related to the estrogen receptor. So there's this whole period of perimenopause. And what's most fascinating to me is that there is this massive, massive change that happens in the female brain that people are not talking about enough. And so looking at the work of Lisa Mosconi at Cornell, starting around age 40, there is this massive change in cerebral metabolism. So you can do FDG PET scans, you can look at glucose uptake. And there's about, on average, a 20% decline from premenopause up to like age 35 to perimenopause to postmenopause. The women who are having the most symptoms in perimenopause, the hot flashes, the night sweats, the difficulty sleeping, those are the ones who have the most significant cerebral hypometabolism.

So it's almost like a, I don't want to scare people with this language, but it's a low level, or let's call it pseudo-dementia of sorts. Yes, it seems to be a phenotype that you can then map to Alzheimer's disease, because that's Lisa Mosconi's work. She's looking at okay, Alzheimer's disease is not a disease of old age. It is disease of middle age. What are some of the biomarkers that we can define that can tell you what your risk is? I've got a mother and a grandmother with Alzheimer's disease. You can believe I am all over this data.

An insulin resistance. Huge part of it. Insensitivity, as we talked about it before, seems to be somewhere in there, which I think when that idea first surfaced a few people are like, really, but then, of course, right? I mean, the brain is this incredibly metabolically demanding organ. You deprive neurons of fuel sources. Or you make them less sensitive to fuel sources. They start dying.

They certainly start firing less. It makes perfect sense. And I think now it's thanks to Lisa's work, work that you've done and talked about quite a lot, is in your books and elsewhere, I think, has really highlighted for people that metabolism and metabolomics is going to be as important as genes and genomics. when it comes to dementia, perhaps especially in women? Is it safe to say that? I think so because we believe that the system is regulated by estrogen.

So the decline in estrogen, starting around age 40, 43 is kind of the average, seems to be the driver behind cerebral hypometabolism. The way I describe it to my patients is it's like slow brain energy. So you walk into a room, you can't remember why. you just notice that you can't manage all the tasks the way that you once could. Like, things are just a little slower. And I say that to women. They're like, I have that.

Like, help me. We've got all of these women that are marching toward potentially a greater risk of Alzheimer's disease. And they have this opportunity in their 40s and their 50s to take hormone therapy. And they may not be offered it because the typical conventional approach based on WHOI is to say, unless you're having hot flashes and night sweats that are severe, I'm not going to give you hormone therapy. And I just want to call that out. I would say no, that is not the way to approach it. The concept right now in conventional medicine is that hot flashes and nights sweats are these nuisance symptoms that we will take care of temporarily. It doesn't matter that you're not sleeping anymore,

turn down the temperature in a room. And that's not right because hot flashes and night sweats are a biomarker of cardiometabolic disease. They are a biomarker of increased bone loss. They are a biomarker of changes in the brain. So many of these symptoms that occur in perimenopause are not driven by the ovaries. They are driven by the brain. I just want to say, you've taught me a tremendous amount. The amount of knowledge that you shared is immense and is going to be very useful and actionable for women in particular. Can I just add one last thing? Because I didn't talk about it Since we didn't get to the 40s and the 50s in those listed biomarkers, if women went away with one thing today, it would be to do a coronary artery calcium score by age 45 and sooner

if you've got premature heart disease. How is that taken? So it's a CT scan of the chest. You can self-order it. It almost gives you this fork in the road in terms of how much you need to pay attention to cardiometabolic health as a woman. It's so fascinating because, you know, there's some women who have. the zero, so my score is zero. But if you're 45 and you're starting to be elevated or you've got,

you know, maybe you've got PCOS or you've got some other biomarkers tending you in this direction toward the number one killer, that allows you to really start to make changes. And I think it's essential to know that data. Most conventional doctors are not going to do it. So if I were to go to my doctor and I just say I want a cardiac calcium score, that's what people should ask. Coronary artery calcium score. CAC. Okay. There are certain people. They are exceedingly rare, but you are one such person that when they speak, knowledge just comes out of them and it's incredibly useful and helpful knowledge. So thank you. Thank you.