The Dr. Josh Axe Show - The Hormone Expert: The Hidden "Gut Bacteria" Destroying Your Hormones!

Starting point is 00:00:00 I think perimenopause is a litmus test of how well we take care of ourselves. We take our hormones for granted until they start declining. Women do really well in their teens, 20s and 30s compensating. They get into their 40s, and as their hormones are changing, as the neurotransmitters are changing, it changes the way you perceive the world and yourself. If we don't change our lifestyle in response to changes in our physiology, it's going to make it a whole lot harder to, you know, get through perimenopause and a menopause. Many women that actually need progesterone replacement actually are being prescribed, anxiety meds and depressive meds. I think a lot of what changes for women is their perception of self.

Starting point is 00:00:39 I used to be able to handle X, Y, and Z, and now I feel so much less capable. The pause piece is really helping women understand. You need to start changing your lifestyle to match your physiology. For millions of women, hitting the age of 40 brings a load of symptoms. and problems. Unexplained bloating, stubborn weight gain, brain fog, and numerous other health issues, emotional ups and downs. Even though their lifestyle hasn't changed. And today I'm joined by nurse practitioner and health expert Cynthia Thurlow. She's a best-selling author. And today we're going to uncover exactly why during perimenopause and menopause, your hormones can be out of balance,

Starting point is 00:01:33 how to bring them back into balance using food, herbs, and lifestyle medicine. And we'll specifically dive into how the liver and the gut microbiome play a key role in bringing your hormones back into balance. Cynthia, welcome the show. Thanks for having me. Well, I'm excited for this conversation because this has been a topic I've been really passionate about is helping women and entire families heal and balance their hormones. And for so many women today, they're dealing with symptoms because of perimenopause and menopause. And this is something you've helped a lot of women with. You've really walked them through how to naturally in most cases, heal and balance their hormones. I've got a lot of questions for you today about everything from hormone replacement therapy,

Starting point is 00:02:14 the top vitamins and supplements for perimenopause and menopause, the root causes. But that's sort of where I'd like to start in getting into is most people today when they think about hormone issues are menopause. They think, well, this is just natural. This is the way it should be. I'm going to have these symptoms. My doctor said, hey, this is menopause. You know, this is just the way it is. is that reality?

Starting point is 00:02:36 I think that menopause, if you live long enough, is a natural process that is correct, but it's not optimal in the sense that we really do have to adjust our lifestyle. We have to address our nutrition. We need to address our quality of sleep, how we manage our stress boundaries, as well as looking seriously at targeted supplementation plus or minus hormone replacement therapy. Because utilizing those levers are going to be a differentiator for who's, just surviving through middle age and beyond and those that are thriving. Yeah, you know, one of the things I've really encouraged my patients to do is not turn to hormone

Starting point is 00:03:13 replacement therapy first. It's not to say that for some women, it's not beneficial because I think there is a group that it's beneficial for, but it's never the thing I like to do first because oftentimes there's underlying insulin issues, liver issues, or as you've talked about for many years, now gut issues, that can be the underlying cause. So when you think about if a woman's going through menopause. Well, first talk to me about what's happening physiologically that can actually cause these symptoms that women have like dryness and hot flashes and some of the other major symptoms that a lot of women are experiencing. Yeah, I mean, I always think about perimenopause from the perspective of what really is the differentiator, the beginning of perimenopause.

Starting point is 00:03:55 It's that our ovaries are making less progesterone. And that can show up as one to two weeks before you get your menstrual cycle, you're suddenly starting having more anxiety, more depression, you can get mood changes. You may feel more anxious. You may also have sleep alteration. So that is definitely a direct byproduct of not just that loss of progesterum, but also changes in a key neurotransmitter called GABA, which is our main inhibitory neurotransmitter. So there's that piece. Then there's also estradiol. It's our predominant form of estrogen that our bodies make up until menopause. And so as estradiol levels are changing, we may see, and traditional allopathic medicine doesn't like this phrase, but I'm going to use it,

Starting point is 00:04:35 relative estrogen dominance because we have less progesterone, and we have relatively more circulating estrodial. And there's actual research to demonstrate that our estradial levels can be 20 to 30 percent higher in perimenopause, which is what provokes a lot of symptoms. We may have brain fog. We may have breast tenderness. We may deal with the dreaded weight loss resistance. We may have a lot of vasimotor symptoms. So hot flashes, night sweats, for a lot of women, they start seeing much heavier menstrual cycles, and that can be bothersome and troublesome. Then we really start thinking about digestive changes, bloating, constipation or diarrhea. They might have an alternation between, like IBS sat patterns, alternating between constipation and

Starting point is 00:05:17 diarrhea, and that's just the tipping point. And so when I'm thinking about what are the some of the key things that we start seeing pretty quickly as we're navigating early to mid-perimenopause, those are the typical things that I'm seeing, not to mention the fact, if we're having alterations in sleep, we are also going to have alterations in cortisol. That's right. And cortisol, and as I always say, it's not a bad hormone, but it gets a bad rap, helping women understand that when cortisol is high, over time, it is going to lead to elevated levels of glucose.

Starting point is 00:05:48 So you will become progressively more insulin resistant. That can also be worsened by changes in estrogen and changes in muscle mass. But cortisol is also catabolic. So if over time, you're super-strategor. stressed all the time, you're not managing your stress appropriately, you're going to get breakdown of that very precious muscle tissue. So sarcopenia starts to unwind, this muscle loss with aging. Not to mention the fact high cortisol is going to beget changes in immune system function, which means you're going to be more susceptible to getting sick. You're also going to be more

Starting point is 00:06:16 susceptible to leaky gut. And leaky gut is really at the basis for autoimmune conditions. And women are four to five times more likely to deal with that. So it really becomes this domino effect of hormonal changes, not just progesterone, estrogen, testosterone, but also these other key hormones, cortisol, glucose, and understanding how they influence and can worsen some of these symptoms that we're experiencing midlife. You know, I always like to look at things in terms of a cascade. Like, what is that thing that's tipping off everything else? And as I, one of the things I do at my clinics is I look at so much blood work. And I see cortisol being one of these hormones that affects every other hormone. And,

Starting point is 00:06:58 you know, I went through this on a recent podcast. I went through the, you know, what some researchers years ago called the cortisol steel sort of cascade, right? And so you have, you know, you've got your, you know, you've got your pregnant alone and sort of how that breaks down then into progesterone and then the other sex hormones. But cortisol is like, hey, I'm going to take all the resources from all, from progesterone, from testosterone, from testosterone, from all the other hormones and take them myself, and that starts to deplete that progesterone. But I think, I mean, that is such a key thing. And one of the thing I thought about as you were talking here, as I was thinking about my own

Starting point is 00:07:33 mom, my mom, the first time she was diagnosed with cancer was 41 years old. And it just reminds me of like so many of the patients I care for and a lot of the women you care for that are entering perimenopause. My mom was in perimenopause. and she had, you know, three kids. She was stressed, definitely high cortisol, high estrogen, low progesterone, all of those issues. And that even led to cancer. And you think about part of what can happen there, too, and that connection between the liver and the gut, her not detoxifying.

Starting point is 00:08:05 Well, by the way, her number one symptoms she would have told you that she was dealing with and struggling with right before her cancer diagnosis. And then especially after it was an even bigger problem was chronic constipation. Yeah. And this is something you write about in your book, how our gut microbiome and especially the health of our bowel movements in constipation is a key factor in, you know, even in our hormonal health. Yeah, and it's so interesting that we have normalized women being constipated because I know when I'm having conversations, I'll say, help me understand what constipation means to you. Because you and I may say, I think you should be pooping every day. That should be normalized. I have patients that think it's normal because it's their normal to poop two or three times a week. And so when you start thinking about the fact that if we are not able to properly package up estrogen, like let's use that as an example, there's a part of the microbiome where there's specific bacteria in the strobalome that help us break down and package up estrogen, which we should be able to then eliminate through our feces, our poop. But for a lot of people, if their microbiome is not optimal heading into middle age, that can make it worse. You can recirculate some of these estrogens, which can magnify those symptoms, not just the hot flashes, vizumotor symptoms,

Starting point is 00:09:21 but a lot of the brain fog and other symptoms that women experience. So normalizing, helping women understand we have two phases of detoxification in our liver, and really then it goes to the gut. And so the gut microbiome is critically important, the health of that microbiome for whether or not we are able to effectively break down, package up, and poop out that excess estrogen. I think a lot of people maybe have a hard time. By the way, I think this is going to be so key for everyone to understand. I think a lot of people don't think of estrogen. Because it's a hormone, they don't think of, oh, I need to detoxify. I think they're thinking, oh, I need a detoxify of forever chemicals and glyphosate and heavy metals like mercury. I needed detoxify those.

Starting point is 00:10:02 But we need to detoxify estrogen. You know, I recently did a podcast on how to do a parasite cleanse. And there are several steps that you can't miss if you want to properly detoxify. And one of those things was like have a binder, you know, certain types of fiber. Like, it'll help with that. But estrogen is the same thing because your liver takes all this estrogen that you have too much of. It packages it, puts it in your gut and says, okay, now get rid of it. But if you have the wrong type of bacteria in your gut, your body can create

Starting point is 00:10:30 these enzymes that basically then these estrogen breaks apart. It can recirculate in your body. So you have all this excess estrogen, increased your risk of breast cancer, can cause these menopausal symptoms, all these issues. But walk me through, I mean, do you have a process for women or some key things in terms of what do women need to do to detoxify excess estrogen properly? Well, I think, you know, from the perspective, we have key organs for detoxification in the body. So our skin, our liver, our lungs, our bowels, so, you know, defecation, pooping, as well as urination. But there are things that make it harder. Like if you're chronically dehydrated. So number one, like really easy thing to think about, are you properly hydrating your body? And I think most of us walk around being

Starting point is 00:11:14 chronically dehydrated. You add in the changes that are happening with estrogen as it's declining. we lose our ability to stay as well hydrated. Like we actually physiologically, in the presence of less estrogen, high FSAH, follicular stimulating hormone, our bodies become much less efficient at staying hydrated. So we become physiologically more challenged, but not impossible. So number one, hydration. Number two is thinking thoughtfully about fiber. And I know fiber has now become the new F word.

Starting point is 00:11:42 Depending on who I'm talking to, they're like, don't talk about fiber. We don't need fiber. We do need fiber. Fiber is very important for a variety of things, but as our hormones are declining, as the microbiome is changing, we need fiber because our production of something called short-chain fatty acids declines.

Starting point is 00:11:58 These are important signaling molecules, and one of the things that they do is they help reduce inflammation. They help with endogenous GLP-1 regulation. I know these drugs are very popular right now, but they're also important for signaling molecules. They can cross the blood-brain barrier like butyrate can. So fiber becomes important

Starting point is 00:12:15 because along with bile, which is designed to break down and emulsify fats, as estrogen's declining, again, we start taking a hit with being able to break down and process fats. So fiber is helpful for binding to these bile acids and effectively helping us package up the excess estrogen and excrete it from our bodies, poop it out. So when I'm thinking about how detoxification works, it's helping women understand we want to sweat, so we want to make sure we're exercising, We want to make sure that we're staying hydrated, that if we have access to things like sauna, that can be very beneficial. Dry brushing, also helping women understand that the fiber piece becomes important. And for everyone that's listening, fibers vary by a individual.

Starting point is 00:12:57 What Josh may be able to consume on a daily basis might be different than what I do, as well as our spouses and other people, patients that we take care of. Also thinking thoughtfully about cruciferous vegetables, thinking thoughtfully about, you know, bitter plants. So whether it's radicchio or freeze or arugula, like those bitter compounds are going to be very helpful and beneficial to supporting detoxification efforts. And I think, you know, there's those other piece of what genetics play a role in. Like I have something called MTHR, which 70% of the population has. I have to work a little harder at phase two detoxification. So having a sense of what your personal things that you struggle with, but also understand there's a lot that we can do before we even get to supplements, before we even get to utilizing medications or even hormone replacement therapy,

Starting point is 00:13:48 there are things that we can do nutritionally. I would say one other thing that's important is the management of stress. I think for so many of us, we go throughout our lives, we're like, oh, I meditate for five minutes on Thursdays. It's so much more unique than that. It's really helping women understand as our hormones are declining. We have to work harder at stress management. So for years, I used to dictate in the hospital or in the office and eat at the same time.

Starting point is 00:14:11 not an optimal way to set your body up for digestion because digestion starts in our brains, not our mouths. If I were to ask kids or most adults, I would say, oh, my mouth salivates when I smell something delicious. That's true, but actually it's under the control of the parasympathetic nervous system. But most of us are eating off our kids plate.

Starting point is 00:14:30 We're eating in the car. We're yelling at our spouse while we're trying to eat a meal. And so digestion, understanding that we want to be on that side of the autonomic nervous system, the parasympathetic, because that is what allows us to, absorb nutrients, break nutrients down, secrete enough hydrochloric acid in the stomach to break

Starting point is 00:14:47 protein into amino acids, ensure that we're secreting digestive enzymes. So if we're chronically stressed, we're not actually able to break down, assimilate, absorb, detoxify, or even eliminate properly. And that's a part of the conversation that I oftentimes think is really left out because people are like, it's not important. Digestion just happens. No, we actually have to foster it. We have to work towards it because it is quite important. As we've talked about in this episode, mitochondrial health is the foundation for all day energy, resilience, and long-term wellness. When your mitochondria are supported, everything works better, from metabolism and recovery to how you handle stress. Now, we've covered numerous strategies

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Starting point is 00:16:17 learn more at sunlighten.com forward slash axe. Use code axe to save up to $1,400 off your purchase with additional savings throughout the year. You said several things there, and I want to just rehash a few of them just so everybody can walk away with something here. And that is reducing stress is one of the greatest things you can do to improve. your overall digestive health and your detoxification. And for most people, it's just, it's all about saying no more and having a little bit more margin in your day, like especially around meal time, taking time to where not being on your computer, not being working at the same time,

Starting point is 00:16:58 just taking 30 minutes and actually eating your meal, chewing, looking outside, just relaxing, and then taking a 15-minute walk afterwards. If you can do that, just around your your meal, just relax, just take a breather for, you know, 15 to 30 minutes. That will make a huge, huge difference in your digestive health. And then as Cynthia talked about here, too, you know, we need fiber and really getting a lot of these key vegetables, especially the bitter vegetables and the cruciferous vegetables. The crucifers vegetables have compounds like Indole 3 carbonyl. They help shuttle and get rid of more of the excess estrogen out of your body. And the bitters support bile flow, which he was talking about, which is really important as well.

Starting point is 00:17:41 So doing everything from dandelion greens, she talked to at Radicchio, you know, watercress, arugula, artichokes, all these sort of bitter foods are fantastic for supporting the flow of bio. And then just getting more fiber, you know, and that could be a blend of soluble, insoluble. It can be from everything from oatmeal to, you know, a lot of the vegetables we already talked about. Those are great sources of fiber. Apples are fantastic sources of fiber, berries, pomegranate. And so just doing some of those things will make a big difference in that detoxification process.

Starting point is 00:18:12 Now, I want to talk about progesterone again because I think estrogen is talked about a lot in menopause. It's talked about more. But progesterone was the first thing you mentioned when I ask you, what starts to happen during perimenopause. So that starts to decline sometimes, maybe even before the estrogen does. Why does that matter? Well, because progesterone is, you know, when I think about estrogen and progesterone, they're designed to balance each other out. There's key attributes of both. I always say that estrogen is kind of the queen. We know so much about estrogen. We talk about it a lot. You know, progesterone is equally important. And I think largely because of the fact that, you know, when progesterone predominates in our menstrual cycle, we tend to need to back off on the intensity of our exercise. We might need to increase our carbohydrate intake. We need to be doing more relaxing because, you know, it is the hormone that is connected with GABA, you know, this main inhibitory neurotransmitter, and how important that is for us to feel like we can relax and we feel at peace.

Starting point is 00:19:14 Can I just gentleman say this? Like when I first opened my practice, functional medicine practice about 20 years ago, I think the thing that I noticed the most and taking care of a lot of women, especially Gen X women coming in, I would say, I would say, I would say, I would say, frazzled. It was like they were just so busy. but I hear words like, I'm overwhelmed. Yes. Like that was the number one key word I would hear them saying, you know, constantly. Yeah. And it's interesting because I think many of us forget these hormones also work in conjunction

Starting point is 00:19:44 with neurotransmitters and the bulk of our neurotransmitters are produced in the gut. So as the gut is changing, you know, GABA takes a hit, things like dopamine take a hit, serotonin. So that also worsens sleep quality. But when I think about the things about progesterone that I think are most beneficial is that replacing, replenishing progesterone for a lot of women will improve their other symptoms that they're experiencing. So if you are feeling less anxious, if you are not feeling depressed, or feeling almost like a flat mood, we'll use the term anadonia in traditional medicine, like helping women understand that a lot of the changes they are experiencing at the very

Starting point is 00:20:21 beginning of perimenopause are largely a reflection of changes in sleep quality, changes in mood that are oftentimes bandated with, and I don't, I'm going to say this. Some people need to be on medication. I don't want anyone to feel any sense of shame. But many women that actually need progesterone replacement actually are being prescribed anxiety meds and depressive meds. And they might still need those as well. But I think a lot of what changes for women is their perception of self.

Starting point is 00:20:49 I used to be able to handle X, Y, and Z, and now I feel so much less capable. And so your point about the boundaries piece and getting really clear and intentional, I really think of it as it's the perimenopause. pause, like the pause piece is really helping women understand. You need to start changing your lifestyle to match your physiology. I think perimenopause is a litmus test of how well we take care of ourselves. We do a great job of taking care of everyone else in our lives, but in many instances, we're not taking care of ourselves. And so this is an opportunity as progesterone is changing for us to show up differently. Maybe you go to bed 30 minutes earlier. Maybe you say yes to less.

Starting point is 00:21:29 And you, unless it's a hell yes, it's a hell no. And so help. helping women understand that the way to support progesterone, and we could talk about, you know, progesterone supportive foods, but really, in essence, what we are inviting women to do is to take more off of our plate at this time. Diabetes, cancer, dementia, heart disease. They are coming for many of us and our families. And not for the reason that most people think, which is that it's bad luck or bad genetics. The truth is this. Your daily choice is, your daily choice. are either creating health or setting the stage for disease at the cellular level.

Starting point is 00:22:07 And your doctor is probably missing the cellular issues behind your symptoms. Now, I'm currently offering a simple at-home blood test that actually looks for the right warning signs in your blood markers. And just as importantly, it comes with a proper review of your results. This new test flips the script. When you're tired of being dismissed, when you know something isn't right, get my at-home testing of targeted biomarkers, including hormones, thyroid, and metabolism, plus a full hour with one of my senior health advisors to help you understand your results and see if you're a good

Starting point is 00:22:42 fit to work with one of our cellular healing protocols at the Health Institute. By the way, these protocols are the same protocols that I created for my mom, that I've created for many patients and clients that have seen incredible results in healing. Grab one before they're gone. Just go to mybloodwork.com. That's mybloodwork.com to get your kit today. I mean, you've probably seen this. And I hardly, I don't spend a lot of time there, but I spend some on Instagram, you know, in social, in Facebook. And, you know, some of these social media platforms, they have, you know, there's accounts.

Starting point is 00:23:17 I've seen a few times where my wife has showed me. We've sort of laughed in terms of, here's what life's like in your 20s if somebody asked you to go out. You don't even know where you're going. You're like, yes, I'm going out, right? your 30s, it's like, I don't know, it better be, you know, pretty great in your 40s. It's like, no. And part of the reason is I think that most of the time by the time people get into their 40s and 50s, there's a sense of overwhelm of, I have kids, I've got work, I've got health problems, I'm overcommitted. And so, in self-care is the last thing that typically people are thinking of.

Starting point is 00:23:51 I want to mention this about progesterone as well. You know, when you look at Chinese medicine, And there's always this, and you mentioned this, there's always this relationship between hormones. And in this relationship, estrogen tends to be what we'd call the Yang hormone, which is the dominant, it's the driver. It's the, but then, and it's actually part of the masculine and feminine, even though we think of estrogen as a very feminine hormone.

Starting point is 00:24:12 But progesterone is the, it's the supportive figure. It's the, I'm creating the foundation. I'm creating stability. It's your point, it's the parasympathetic. It's the most closely tied to that. So if that dips, well, your body, I mean, your body is lost its support, you know? And so then estrogen starts to run rampant, causing all types of issues. So I mean, progesterone, you know, do you know Barbara O'Neill? I do. So I had Barbara on the podcast last year. And we talked

Starting point is 00:24:38 about numerous things. And I was so impressed with her. By the way, her ability to quote the Bible in scripture was amazing. Her hormonal knowledge, women's health knowledge, was just natural health, was all very impressive. But when I asked her about female hormones or hormones in general with the single most important hormone was, I tend to lean towards cortisol. But she was very much like, you have to balance progesterone. She was like, that is the key hormone that she found in women that you really need to focus on. Well, and it's interesting for me, you know, having work with tens of thousands of women over the past 10 years, I can tell just based on behavioral and communication patterns, the people that probably are not getting sufficient amounts of progesterum, much more

Starting point is 00:25:22 so, like, estrogen can show up as, like, word-finding and brain fog, but progesterone is the, are you relaxed and calm? Are you able to communicate effectively and not feel like you're, you know, you're jumping through the screen? And so I think for a lot of women, they're surprised to know, because we take our hormones for granted until they start declining. We don't even think about it because they're just working for us. And if we don't change our physiology, if we don't change our lifestyle and response to changes in our physiology, it's going to make it a whole lot harder to, you know, get through perimenopause and a menopause. You know, one of the things I've taught for a long time, and I know you do this in your book

Starting point is 00:25:57 and you talk about this as well, which is one of the reasons I wanted to have you on, is really focusing on food as a form of medicine for our hormones. You know, I was thinking about and looking at the Japanese diet and looking at some of the predominant foods in there. And so you have things like fish is, of, of course, highly consumed. But they actually also consume a lot of in terms of their carbohydrates, most consumed are rice and sweet potatoes. Yeah. And what's interesting about rice is it supports GABA, sweet potatoes can or yams support some level of progesterone or giving the building blocks there.

Starting point is 00:26:28 So, you know, of all countries where women are going through and having the least symptoms during menopause, Japan, the area of Okinawa is very high on that list. But I look at their diet and it is a form of medicine at supporting them as they're going through, you know, this phase in life. Well, and what I think is so interesting about their culture is they, well, like most westernized culture, there, is processed foods, but they tend to be very conscientious about the quality of foods that they're eating. And so, yes, they're eating carbohydrate dense, rice, and sweet potatoes, but they probably are not eating the volume of processed carbohydrates the most Americans are. And I think that is at the basis, you know, there's been a lot of pushback about carbohydrates in general, and people are sometimes shocked to hear that I'm oftentimes encouraging women to liberalize their healthy carbohydrates

Starting point is 00:27:15 because they have dialed in so much on carbs are bad. I only need to worry about protein and fat. And I'm like, no, no, no. You actually need a balance of each, and it's very bio-individual. But I think your point is an excellent one because we have convinced women that all carbs are bad in many instances.

Starting point is 00:27:33 And I'm here to tell you, a proper portion of carbohydrates can make the difference between sleeping well and not sleeping well. For many patients that are really, really sensitive to carbohydrate intake and carbohydrate load. I saw, you know, when the paleo diet became really popular, that is when I started seeing a lot of women with these hormonal crashes with actually some of them with infertility issues, major health problems because it was like, oh, I mean, most of those women that went paleo was like no carb. I mean, they went from, you know, whatever flour they were using to almond flour, right?

Starting point is 00:28:05 They made all of these switches. And so it really does come down to it. I love that you're using the word bio individual. It comes down to this personalized nutrition. Everybody's unique. We need to dial it in for everybody. And let me ask you, how do you do that in your practice, you know, in working with women in terms of finding what uniquely they need to be eating and supplementing with? Well, I think it's starting with key themes.

Starting point is 00:28:27 So number one, we all know we need more protein. I think we have, that is definitely trickled down into, you know, media. People understand more protein for muscle protein synthesis because we are working at a little bit of a disadvantage. Women have less lean muscle tissue than men. So heading into perimenopause, understanding we're losing anywhere from three to eight percent of our muscle mass each decade really is a wake-up call. So protein, no less than 30 grams of protein with each meal, that's kind of a standard basis. Number two is thinking thoughtfully about carbohydrates. I am not anti-carb.

Starting point is 00:28:58 If someone is obese or overweight and we know that they have weight they have to lose, then we're talking about portions of carbohydrate and getting really clear and intentional. I want the bulk of your carbohydrates to be coming from fibrous vegetables. And I would say it's a three to one ratio, three vegetables to one piece of fruit. It doesn't mean fruit is bad. It just means we have a propensity as Americans to eat sweet things. And fruit usually is where people eat the bulk of their carbohydrates. So three vegetables to one piece of fruit, being thoughtful. Like I don't necessarily break it down by soluble versus insoluble or looking even at, you know, ferment.

Starting point is 00:29:34 It's eat more of them. It's getting clear and intentional about fermented foods and probiotic rich foods. that may look like a tablespoon or two of sauerkraut. That may be low sugar kombucha. That may be fermented dairy if they tolerate dairy, you know, just being clear and intentional as a starting point. Now, fats are something that I think, again, are also very bio-individual. I'm someone that doesn't do well with saturated fat. Although I do have a little bit of it in my diet, I do better with mono-unsaturated fat. So getting clear about, you know, are we getting our healthy fats in our protein? Like if you have a salmon steak or a ribbite, you don't need to add copious amounts of fat. That is the

Starting point is 00:30:12 fat memo that I think many women get wrong because it's interesting. If you look at the research, two women can have a ketogenic diet, which we would arguably say is higher fat, moderate protein, and then less carbohydrates. One woman goes on, that diet and does really well. She loses weight, she feels great. The other woman, same diet, same macros will actually gain weight. And it could have something to do with how her body breaks down and absorbs nutrients. So really looking at the microbiome, which I think is important. But key concepts are adequate protein intake, getting most of your fiber from fibrous vegetables, you know, looking thoughtfully at, you know, flax and chia seeds, or looking at lentils or beans or other legumes. It doesn't have to be copious amounts. And then those

Starting point is 00:30:59 ferment and probiotics, that's usually a good starting point. And then not getting obsessive about the fat piece because a lot of the fat is in the foods that you're, and if you're having macadamia nuts or you're having nuts, you're getting healthy fats and those things. So not obsessing over fats, but just making sure it's incorporated either into the protein or adding it in as a supplement. Yeah, yeah, that's fantastic. Use a word earlier, and I'd love for you to explain what it means, esterboloom. Everyone loves this word, and it's not astrobalomi. I actually had a podcast host say the estrobolomi, and it took a while for me to regain my composure, but it's a part of the microbiome. It's an estrogen processing center. It's actual

Starting point is 00:31:39 bacteria that are designed to break down and allow us to package up and get rid of estrogen. And so for a lot of people, the astrobiom, the health of the astroblum is largely dependent on all those lifestyle things that we've talked about. It's dependent on, you know, where is the microbiome in terms of diversity, inflammatory species heading into perimenopause. This is why it's important to educate younger women. It's not just a middle-aged woman conversation. But the astroblum is instrumental for the specific bacteria that help break down estrogen. There's a specific enzyme called beta-gluceronidase, and it's the Goldilocks effect. If you have enough beta-gluceronidase, you can break down and package up the estrogen. If you don't, it can be a sign that you may

Starting point is 00:32:23 recirculate this estrogen. And so sometimes when we're doing diagnostic testing, as I'm sure you're doing your practice, you can see high beta-glucuronidase, which can be a sign that. that their detoxification pathways or their detoxification overall needs additional support, but a really important essential part of the conversation. And no, I did not make this name up. Someone else, far smarter than me, more than 10 years ago, came up with the term astrobalone. But it is speaking about the microbiome and specifically the bacteria there that are helping to break down cleave and get rid of the excess estrogen. Well, it's incredibly important, you know, and that's one thing I know that you've really talked

Starting point is 00:33:00 about it is like one of the number one, if not the number one organ that is responsible for hormone balance is your gut microbiome. And part of that is the esterbolome. And so I am in really strong agreement. Now, I would say that I think of it a little bit more in terms of just the, and you think of it this way too, but just in verbalizing this, just the entire process of digestion because I would say the liver is equally important. And they're kind of partners in the liver and the gut in making this all happen, right, in terms of what happens in the I also think about, you know, I work with so many women with hypothyroidism, and we see this issue with the conversion of T4 to T3. By the way, you might have seen this study. The study came out about a month ago.

Starting point is 00:33:43 It was in JAMA. It was in a study out of Yale where they said, I mean, this is crazy. 21 million women today on levothoroxin possibly should not be on the drug at all. I mean, they said like 90% of women, it's not supporting them. but it is causing depletions in selenium, zinc, certain B vitamins. So women have been on levothiroxin, this thyroid medication, for years, some of them 20 years. And it's slowly been causing these other health issues, making maybe their thyroid issues worse. So when they get off it around menopause, they're like, well, either I feel better or my symptoms didn't change at all, and I've been on this drug that long.

Starting point is 00:34:24 Well, it's interesting. So cynthroid is synthetic thyroid hormone. And what's interesting to me is I had patients that loved synthroid and were like, they would go in the hospital. They're like, I will not take a generic. I only want trade name synthroid. But just giving a medication doesn't necessarily mean that your body knows what to do with it. So when you're giving synthroid, this is synthetic T4. Your body still has to take that and make it into usable energy, which is T3. And I think for a lot of individuals, they're given these medications. They don't necessarily feel better.

Starting point is 00:34:55 And they're continued on them because they don't know any. differently. And so I think that there's very much this bio-individual approach, but also understanding the health of your microbiome is a lot to do with whether or not your body can effectively convert T4 to T3, which is the usable form of the thyroid hormone, not to mention the fact with our depleted soil and other things that are going on in our modern-day food system, people are already dealing with lower levels of co-factors for thyroid hormone, whether it's iron, whether it's magnesium, whether it's selenium, zinc, etc. And so it's really looking at a, I think it's a bigger issue. Yeah, yeah. And I think for a lot of women that will get on

Starting point is 00:35:31 T4, level thyroxin or synthroid, sometimes they'll notice a difference at first because, okay, you're flooding in the body, but then sometimes the body kind of adapts, or you didn't take care of the underlying issue, like the high cortisol or something like that. So then you have other sort of problems compiling. Well, you've just sort of covered up, you know, maybe some of these baseline symptoms with the drug. And this is why I am more in favor of, like, a woman using. And, you know, nature, throid or armor or something like that that does have T3 in it and that combination. But overall, what I found is if you are changing your lifestyle, eating the right diet, taking the right supplements like selenium and the other things, most of the time you'll

Starting point is 00:36:10 see bigger improvements to where you don't need to be on the thyroid drug. But I remember, there are a lot of women who their doctors have told them, you'll be on this drug the rest of your life. It will never, ever change or improve. Well, it's interesting to me. So I will transparently say that 10 years ago, my functional med nurse practitioner was like, you need thyroid medicine. Like your thyroid numbers are terrible, and we were looking at them, and I said, I don't want to be on medicine for the rest of my life. So for six months, I was taking a thyroid glandular. I was using all these cofactors. And six months in, I realized, I was like, I am exhausted, I cannot function. My hair is falling out.

Starting point is 00:36:46 I'm losing my eyebrows. What is going on? I'm also weight loss resistance. it was probably my largest impetus for like, okay, there's something clearly going on here. When I got started on nature thyroid, it was as if a light bulb turned on in my brain. Yeah, yeah. It was that dramatic. And so I always remind women, I think for many of us, we're like, I don't want to be on medication. But I think we have to think about hormones differently. I think we have to be thinking that if you need it and you benefit from it and you see

Starting point is 00:37:13 improvement intrinsically on labs and in terms of symptoms, that's great. But to your point, a lot of patients and in terms of. traditional antelopathic medicine when I was still in that role. Synthroid was what everyone used, but we didn't understand that sometimes patients can't actually convert it to a usable form of hormone. And that's where I think these nature, thyroid, and armor can be helpful or even compounded medications that are made, they're specifically tailored for the patient. I think for a lot of women, it's helping them understand there's no shame if you need meds, but we need to make sure you actually feel better on the meds. Yeah, yeah, I agree. And for me, and I'm not saying, and just to be clear,

Starting point is 00:37:50 I do think there's a time in place for those. But here's my methodology. It's let's change your diet. Let's change your lifestyle. Let's take all the right supplements. So do the blood work. Let's see exactly what you're deficient in. I found 80% of the time we'll get you there.

Starting point is 00:38:03 And then if we don't, well, then we'll do this for a period of time. And maybe the reason why it's not being fixed is you're going through a really stressful time in your life. Cortisol is staying high. But a lot of times after a couple of years, maybe we're out of that phase. And we can find a way to wean you off that over time. But that's not the mindset of most. Doctors Day even, it's just, it's not that. Yeah, no, absolutely.

Starting point is 00:38:24 And I think, you know, for each one of us as individuals, something that works for you or five people over here might be very different than what works for me. And that's where I think honoring our own bio-individuality. And quite honestly, I have patients that'll say to me, I want to do everything I can to avoid taking medicine. And I'm like, we can work with that. But if we get to a point where you're going to benefit from a medication, I want you to feel

Starting point is 00:38:46 no sense of shame for that being the case. Yeah. Yeah. It makes sense. So when women start going through this perimenopause and menopausal period, you know, there are things that I know we want to do to start to support the body. What are some of the things? We talked a little about food. We talked about fiber, increasing protein, you know, eating more probiotic-rich foods. I know these are important. What are some things people can do

Starting point is 00:39:09 from a supplement standpoint? Are there any more, even more essential vitamins, nutrients, other compounds that can really benefit women? Well, I think at a very basic level, almost every patient I interact with needs, magnesium replacement, has 400 enzymatic reactions in the body. And as a former cardiology nerd, there are very few women I interact with that don't need magnesium. So magnesium's number one, vitamin D being thoughtful about that. I would say that adaptogenic herbs are some of my favorite things to use because they are so tonifying for cortisol. So we've talked a lot around cortisol, but there are specific adaptogenic herbs. These are natural plant-based compounds that can help tonify. If you need to be stimulated, like you're feeling tired, you know, ashwaganda is great

Starting point is 00:39:52 because it can be both stimulating and also tonify, meaning it can help raise cortisol, can have balanced cortisol. And I think that's always a good one. If someone's struggling with sleep, we start thinking about rodeola, Rola, Rola, as being fantastic options. So adaptogenic herbs, I think a lot about creatine monohydrate. And I think many people like the Jimbrose know it's good for strength gains, but the research is starting to evolve in a way that it's very thoughtful. It can help for jet lags, sleep architecture, how many women in middle age are struggling with sleep issues. Also, bone health, but obviously you need higher doses if you want to cross the blood brain barrier. And so typically we're saying 8 to 10 grams is what we are looking at if we want to be able to do brain, bone support.

Starting point is 00:40:34 And also some emerging research about the gut microbiome. So I think creatine is one of these supplements that can hit multiple things. And I love when supplements have more than one indication. I also think about digestive support. So if I suspect someone needs hydrochloric acid or pepsin, looking at digestive enzymes, one of my favorite supplements for middle-aged women is Tudka, which is an acronym. But it is helpful for bile acid support, but also mitochondrial support. And really at the basis for a lot of the symptoms women experience in midlife, and frankly, for men too, is mitochondrial dysfunction.

Starting point is 00:41:11 So I think a great deal about that. I would say other things like urolithinae, we know more. Most people can't get enough from the food, unfortunately. Our microbiomes are largely dependent on that. So, you know, yes, you can have pomegranates. Yes, you can have walnuts, but urolithine can be very helpful for upregulating mitophagy, which is getting rid of those disease, disordered mitochondria, which are the powerhouses of our cells. But those are like maybe myoanacol too because it helps a lot of women's sleep.

Starting point is 00:41:38 I think, you know, before the JLP ones came around, we would talk about myoanacetal for blood sugar support or berberine, which are still helpful to a point, but I think about myoanacetal is a total game changer for sleep support in many, many ways. Those are things that I think about like most women benefit from those, even if it's just transiently.

Starting point is 00:41:58 Like maybe someone just takes the adaptogenic herbs around stressful circumstances, but those are the things I'm thinking about. Now, obviously there are more things that I love, but I try to keep it kind of condensed. Do you need digestive support? Do you need sleep support? What's going to be a multifactorial

Starting point is 00:42:14 supplement that you can use, and that's why I think creatine's such a great option. And I think for women being able to pinpoint, as you talked about, this personalized medicine of figuring out what is it that your body needs most? Listen, you can't take 100 supplements. But being able to key in on, is it cortisol? Is it a nutrient deficiency? You know, is it really driven by estrogen or progesterone just dropping so suddenly, then there's black cohosh and red clover and a lot of those sort of herbs can be great. But overall, I love, I mean, you know, a lot of these adaptogenic herbs that are getting cortisol back in. and balance because that is, of course, incredibly important to your point there as well.

Starting point is 00:42:50 Josh, people always ask me about fiber, like fiber supplements. And I would say, try to get it from food-based sources first. If you're really deficient and you're really struggling, then we try to keep it simple, like cillium husk, organic cillium husk is a good option. Fresh ground flax and chia seeds. I think that is so gentle. I'm like, I always say to people, I'm like, listen, put it in a smoothie and call it a day. It's such an easy way to bump up. not only your protein intake, but also giving you some good fiber intake as well. Yeah, I totally agree. So Cynthia, one of the things that's happening so often today in our conventional medical system is when women have their hormones start to become more imbalanced,

Starting point is 00:43:30 more apparently imbalanced, they're running to HRT. And this happened even more so I saw the natural health community. It was funny because I saw when they removed the black box warning, RFK did, I thought to myself, you know what? I understand that. That's fine. It makes sense. But also, it was this thing where it's like liberating women. And I thought, well, I don't know.

Starting point is 00:43:54 I mean, the thing that I worried about with it, I'm just being real honest. By the way, my heart is very much thinking about my mom who had cancer, my wife, my sister, my patients, and people who I didn't want them to think, oh, well, that just means it's completely safe. if it's the first thing I should do and run out and get hormone replacement therapy. Because I thought some people, even in the natural health community, kind of came out, and that was a little bit of their demeanor. Now, listen, everybody has a different opinion. My opinion might be different than yours.

Starting point is 00:44:22 But I also want to say, I have had three women, and we take care of a lot of and support a lot of women with cancer in my clinic. And I had three women. They were on their 30s, got on hormone replacement therapy, and the next year diagnosed with breast cancer. And I see it often. Now, I do want to say that I do like hormone replacement therapy for the right woman at the right time if they're doing the right things, right? But, again, my issue has been that, and I'd say the same for TRT for men.

Starting point is 00:44:53 Right. It's like, okay, your testosterone's low, your free testosterone's low. Let's do some zinc. Let's get vitamin D. Let's get boron. Let's lift weights. Let's get better sleep. Let's, you know, let's do what we can.

Starting point is 00:45:08 if we're still having issues in three months even, okay, there's a time in place, you know, there's a time in place for that. But so often today, people just want to do the cookie cutter thing and just say it's, oh, fine, everybody, just if you want it, here you go, versus personalizing this for women out there. What are your thoughts on HRT? Yeah, so I think you bring up some good point. So number one, it is very much a personalized approach. I think that we have whittled perimenopause and menopause down to just slapping on an estrogen patch and piece out. That's all we have to do. It's not to suggest that hormones are not important.

Starting point is 00:45:41 I take hormone replacement therapy, so I want to be fully transparent. What I think is important is that when we look kind of globally at women, and certainly when I worked in clinical cardiology, I saw a lot of older women in the ICU that were septic, and they were septic because they had a urinary tract infection, which could have been prevented by something as simple as vaginal estrogen, which stays very localized to the vagina. So I'll just put that out there. 70% reduction in hospitalizations just with vaginal estrogen. So vaginal estrogen for all women, because genitone urinary syndrome of menopause is not a question of if but when. So that's like,

Starting point is 00:46:16 that's one thing. And even cancer survivors can safely take vaginal estrogen because it's not systemic. Ideally, it's not systemic. It's not supposed to be systemic. When I think we're talking about a larger conversation to lifestyle, it is lifestyle first. We really have to manage stress. We have to prioritize sleep. We need to eat less often. It doesn't mean everyone's intermittent fasting. We need to eat anti-inflammatory nutrition. We need to lift weights and maintain muscle mass. And then it's also thinking about like when do we layer in hormones. Is that appropriate? Is that what the woman wants? Number one, I think fully informed consent is talking about here are the pros and cons. We know that estrogen can be primary prevention for osteoporosis, which is a bone

Starting point is 00:47:00 disease. And we don't want that to happen. So it's helping women understand, do we we start with oral progesterum when you're in your early 40s when you can't sleep and you have anxiety and depression. I think that is reasonable. I think that, you know, do we layer in estrogen? Is that appropriate for you? So again, it's this ongoing conversation. What are the benefits? What are the risks? Looking at estrogen therapy and saying, what are the benefits of estrogen therapy? Are you going to get improvement in cognition? Are you going to have less brain fog? Are you going to be able to not struggle with word finding. Are you someone that is going to be able to protect your bones? Are you going to have, you know, improved skin? Are you going to have a reduction in

Starting point is 00:47:42 cardiovascular disease? That is the number one killer of women. One in three women will die of heart disease. So I start to talk about helping women understand, like, if you're making this decision, whether it's to take HRT or not, understanding that there is still this inflammatory process that is going on behind the scenes, changes in immune system function. We didn't even touch on that, but the immune system starts to unwind four to five times more likely to develop autoimmune conditions in midlife. So when I'm talking to women, helping educate them about changes to brain health, changes to bone health, changes to heart health, microbiome, immune system function, mood peace, and not to mention the superficial stuff. Like we know as we're losing estrogen,

Starting point is 00:48:25 we're losing collagen in elastin, so we'll start seeing changes in our skin. as well as body composition. It's like, what are we going to do to augment for that? And so I think that's part of the conversation. We're not looking to replenish hormones back to when we were 20. What we're doing is to provide enough hormones so that we're reducing symptoms and protecting all those body systems I just talked about. And unfortunately, I think that a lot of people just think about HRT is bone brain heart health. And I'm like, no, no, no, these hormones touch every single cell in the body. And so I think as I understand more about the conversation, it's just helping women understand, here are your options, what are you comfortable with? And it's no longer this

Starting point is 00:49:04 five-year window. Like, you go into menopause at 47, you can only start hormones within that five-year window. We know that it's also about, like, risk stratification. So if someone's 60 and they're 10 years into menopause, can they think about HRT? Yes, but, you know, it requires a cardiovascular risk evaluation. They'll probably do, you know, I prefer doing CT angiore. Andes. You know, or clearly, but you can also do a coronary artery calcification scan, which is not invasive and very inexpensive. But really getting a sense of what's your personal risk? What are you comfortable with? And then getting clear and intentional about what you desire to do and matching you up with a clinician that can help you with that. Yeah, yeah. It makes sense. Again,

Starting point is 00:49:46 the whole thing I've been trying to preach here for a long time is let's get your own body working again to its ideal state and then see where we're at. and that's and that's not what I see being done most of the time you know and it's like okay if cortisol's too high if estrogen's too high if your gut is off as your liver's off let's do everything we can to naturally fix those things and then if you still need there then hey I'm glad it's there but that's again that's that's happening in you know less than 10% of cases unfortunately good news is as we've been talking about there are so many natural things that people can do to balance your hormones last question I have for you and this is something that I know you've written about

Starting point is 00:50:24 And it's something that I talk about on the show to a degree, but you really hit on it in a different way, and that is how stress can impact, and not even stress that we're having today, but stress that people have had 20, 30, 40 years ago, how that's impacting their hormonal health and actually causing organs to age more quickly. Yeah, you know, Josh, this is one of the aspects

Starting point is 00:50:48 of writing the book that I found shocking, was that understanding the research that is done. There was a joint venture between, Permanente and the CDC looking at adverse childhood events and anyone watching or listening can go online and you can get access to a fairly short quiz. But individuals with high ACE score, so adverse childhood events are at greater risk for poor metabolic health, certain types of cancers, distorted relationships with food, and earlier menopause because our ovaries are our most mitochondrial dense organ in our bodies. We've been talking a lot about cortisol. Cortisol is not a bad

Starting point is 00:51:22 hormone, but it gets a bad rap. And if we understand physiologically what's happening when we are chronically activated in our sympathetic nervous system over time, that is rewiring our autonomic nervous system. That is rewiring our perception of stress. So if you have a high ACE score, like I do, growing up, and not even, I'm a very, you know, on paper, from what everyone can see, very successful, women do really well in their teens, 20s and 30s compensating. They get into their 40s, and as their hormones are changing, the neurotransmitters are changing, it changes the way you perceive the world and yourself.

Starting point is 00:51:58 And so I always say that, you know, many women who are really well regulated in their earlier years start to unwind in midlife. And a lot of it has to do with significant underlying trauma or even PTSD that are as unwinding as our physiology is changing. We just don't regulate quite as effectively. That doesn't mean that that's the end.

Starting point is 00:52:19 It just means that we have to work a little harder. For me, I left traditional allopathic medicine 10 years ago, had a lot to do with, like, I could not manage the stress of that work anymore. And I think for a lot of women, it's helping them understand chronic stress ages our ovaries, full stop. And so most mitochondrial or mitochondrial dense organ in our bodies, it's the canary and the coal mine. So when I see women that are going to menopause early or going in at 45, 46, 47, 48, maybe that's naturally where they were going to be.

Starting point is 00:52:49 but more often than not, when we start unpacking their childhood, their young adulthood, almost always having significant, significant PTSD or trauma that is, I think, contributing to what they are experiencing at a younger age. Average age of menopause in the United States is 51. 45 is quite different. That means you're going six additional years without those protective hormones. Well, you know, I think about this, there are phases in your life where you really know, it's, okay, you're aging more quickly.

Starting point is 00:53:16 You know, I've talked about this and you've talked about this in terms of, all these excess chemicals in our food supply and how women are hitting, you know, girls are hitting mencies way earlier than they should. I mean, if you look back, a lot of times it's 11 years old, 12 years old, 13, it should be closer to 16 or 17. I mean, much, much later on. And then you have this other shift as you're talking about in life

Starting point is 00:53:38 where your hormones are diving down so much quicker. And this is a sign of premature aging. You're aging more quickly. You know, in Chinese medicine, that error of the body is tied with fear. And so if there's a lot of fear in your life and, you know, narratives from the past or beating yourself up, negative self-talk, you actually are aging that organ more quickly. You know, there's a study a few years ago that found that, you know, we can look at blood work too and look at certain markers to see that for most people, they have one organ aging more quickly more quickly. Yeah. More quickly than another. And so for you, if it's your ovaries, if it's your reproductive organs, it's going to impact your whole body.

Starting point is 00:54:14 You're in tight, not only are your ovaries aging more quickly because they're so responsible for things like estrogen. Yeah. And progesterone, it causes your whole body to age more quickly. So it's a really big deal for longevity as well. Yeah, and I think, you know, the big takeaway I want, you know, if someone is listening and they're like, yeah, I did. I grew up and I had an abusive parent or I was physically neglected or there was significant abuse. It's helping them understand, like, you can come out on the other side. That is not, I don't want the message to be that it's doom and gloom. It's understanding. You have to do a little more work. Like, you genuinely have to do a little bit of extra. But I think for most women, they want to feel regulated. They want to feel good in their bodies. They want to have good interpersonal relationships. skills. I always look at the statistic that 70% of a divorces are initiated by women. How many of those divorces are initiated by individuals that are dealing with all the neurotransmitter change, the hormonal fluctuations, and their ability to compensate is just not what it was when they were younger. I mean, this is a much deeper topic here. I think part of this has to do with the sort of lack of biblical literacy. Like in school, people used to actually have a lot more Christian education.

Starting point is 00:55:22 and then they learned stories of the Bible and had a relationship with Jesus, and so they were better able to balance themselves. I mean, sort of that spiritual wisdom and understanding allows you to better regulate your emotions and hormones. That's actually been pulled out of schools. That's a whole other show, a whole other topic, but I actually think that's another reason why there's sometimes this level of emotional instability or having trouble regulating emotions is because if you, don't believe in a God who's protecting you and for you and surrounding you,

Starting point is 00:55:56 of course you're going to have a greater level of fear and anxiousness and worry in your life. And so I think that's important as well. Well, I've loved this conversation. And Cynthia, I really appreciate you coming on. I want to encourage everybody, check out Cynthia's new book just released here recently called The Menopause Gut. It really walks you through how to fly through menopause, the right foods to start eating. A lot of what we talked about, but going in more depth here in her new book.

Starting point is 00:56:20 It's in bookstores nationwide. It's on Amazon.com. Again, it's called The Menopause Gut. Also, you can find more about Cynthia on her Instagram page and her social channels. Again, check out Cynthia Thurlow there as well. I want to say thank you everybody for tuning in here to the Dr. Josh Act show. Remember, every week we're diving deep into the science and principles of how you can heal physically, mentally, and spiritually. Also, make sure to subscribe, like, and share, and leave a five-star review on Apple Podcast. I can't wait to see you on the episode. Hey, if you're watching on YouTube, I'd love to know what is the number one thing that Cynthia shared today or that we talked about when it comes to healing your hormones, supporting

Starting point is 00:57:00 your bodies, you go through perimenopause and menopause. We'd love to hear from me if there's any action steps you're going to take, anything you learned, and what you're going to do about it.

The Dr. Josh Axe Show - The Hormone Expert: The Hidden "Gut Bacteria" Destroying Your Hormones!

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