The Liz Moody Podcast - I Asked a Harvard Gynecologist Every Q Women Are Too Embarrassed to Ask

Episode Date: July 29, 2026

What’s the vaginal microbiome? How do we know if it’s healthy? In this episode, I asked a Harvard and MIT trained Gynecologist these vaginal microbiome questions + the questions you’ve been too embarrassed to say out loud about your own vagina. My guest is Dr. Sara Szal, a board-certified gynecologist and functional medicine practitioner with 30 years of clinical experience. She is one of the most prominent voices at the intersection of hormones, the vaginal microbiome, and women’s health. We get into every question you’ve ever had that’s related to your vaginal health. 🎧 What you’ll learn: • If your vaginal microbiome matters more than your gut microbiome • How sex, new partners, and semen affect your vaginal health • Antibiotics, tampons, and tight leggings affect on your vagina • How to properly clean down there in a safe way • What vaginal smells are healthy and what are not • If hormone replacement therapy is for everyone • The breast cancer risk factor people don’t talk about enough To assess your lifetime risk of breast cancer, take the Tyrer-Cuzick Risk Assessment Quiz Dr. Sara Szal recommended. For more from Dr. Sara Szal: • Substack: https://saraszalmd.substack.com/  • Website: https://saraszalmd.com/  • Books: https://saraszalmd.com/books/  Ready to uplevel every part of your life? Order Liz’s book 100 Ways to Change Your Life: The Science of Leveling Up Health, Happiness, Relationships & Success now!  Connect with Liz on Instagram @lizmoody or online at www.lizmoody.com. Subscribe to the substack by visiting https://lizmoody.substack.com/welcome.Buy our cute sweatshirts, conversation cards, and more at https://shop.lizmoody.com/. Use our discount codes from our  highly vetted and tested brand partners by visiting https://www.lizmoody.com/codes.  To join The Liz Moody Podcast Club Facebook group, go to www.facebook.com/groups/thelizmoodypodcast. This episode is brought to you completely free thanks to the following podcast sponsors: • LMNT: head to DrinkLMNT.com/Liz to get a FREE 8-count sample pack with any order. • OneSkin: go to OneSkin.co/Liz and use code LIZ to get 15% OFF for a limited time. • Seed: go to Seed.com/LizMoody and use code LIZMOODY to get 25% off your first month. • Masterclass: head to MasterClass.com/LizMoody for an additional 15% off. • AG1: visit DrinkAG1.com/LizMoody and get an AG1 Flavor Sampler and a bottle of Vitamin D3+K2 for FREE in your AG1 Welcome Kit with your first AG1 subscription order. The Liz Moody Podcast cover art by Zack. The Liz Moody Podcast music by Alex Ruimy. This podcast and website represents the opinions of Liz Moody and her guests to the show. The content here should not be taken as medical advice. The content here is for information purposes only, and because each person is so unique, please consult your healthcare professional for any medical questions. The Liz Moody Podcast Episode 452. Learn more about your ad choices. Visit megaphone.fm/adchoices

Dr. Sarah Saul, welcome to the podcast. I was inspired to do this episode because Brian Johnson, who is the biohacker that famously injected himself with his son's blood, he is trying to live forever. He tweeted about his girlfriend, Just gave Kate oral sex. Good night. And then he later followed it up with. This is her vaginal microbiome report. A hundred out of a hundred score top 1% of all vaginas.

A vaginal microbiome is downstream of everything. sleep, glucose control, stress, gut health, sexual health, immune function, what you eat and what you put in it. I feel like societally nobody is talking about the vaginal microbiome. You are a Harvard and MIT trained gynecologist. You are conducting a lot of cutting edge research on the vaginal microbiome. You've written tons of books. So I wanted to have you on here to ask you directly, do we need to care about the vaginal microbiome? Welcome to the Liz Moody podcast where we believe that there is always something that you can do create a life that feels amazing, and we help you figure out how to find the lever to pull at any moment to actually do that.

We absolutely need to care. It felt like a cultural moment when Brian tweeted about giving his girlfriend oral sex and then in short order talking about her vaginal microbiome. And my first response was ick. I think Cucci Carfax is sort of the term that's been given to what he tweeted. Wait, cootchy car facts. Meaning like almost like he's describing a car. Oh, that's so interesting. The way that he described the vagina of his girlfriend.

Like it's an objectification in a whole different way that we've never done before. Exactly. Like, I'm not telling you about my girlfriend. I'm telling you about the data on her vaginal microbiome. So on the one hand, I care so much about this because it's been since the vagina monologues that we've really talked about, the vaginal microbiome. in this way. But I also feel like, why is his diary now including the most intimate details about her? So I kind of love those juxtapositions. So we need to be talking about the vagina.

It's so different than the microbiome of the gut, which has kind of gotten its due. The vagina is not. Never gets its due. We have to change that, Liz. But that moment really creep me out. cream me out and let's talk about lactobacillus crisp bottom because it's such an important defender in the vagina and we all need to be dominated by this particular bacterial species. Yeah, it is interesting because there's both this objectification element and then also I think for a lot of us we're feeling very fatigued and burnt out on like, oh my gosh, another thing I have to add to my list. And it's like, wow, so I wasn't worried about my vaginal microbiome. And now that's like a whole other thing I need to add to my plate. So is this something all of us need to be paying attention to?

Or something that only if you're dealing with some sort of issue you need to be paying attention to? It's a great question. What we know is that women who've got lactobacillus crust bottom as their dominant bacterial species, it provides a level of vaginal health that you don't see when it's not imbalance. So women who don't have this as their dominant species are more likely to have those problems that you listed. So recurrent bacterial vaginosis, which is dominated by Gardnerella. Preterm birth when you're pregnant, you're more likely to develop sexually transmitted infections if you've got PV. So there's a level of defense with L. Crosbottom that you don't get if it's not dominant. How many of us need to be worried about this? I would say most women, but the question about

prevention versus treatment, I would say is still not completely clear. What do you mean by that? Like how much we're supposed to be thinking about this on a regular basis versus if we're dealing with an issue, we like jump in and work on our vaginal microbiome in that moment? Well, it tends to be the women who've got recurrent infections. So that could be with bacterial vaginosis or it could be with recurrent yeast infections. So it tends to be the women that have a problem, maybe they had preterm labor in their last pregnancy, who get focused on this. Your question, the way I understood it, was, do all of us need to be concerned about this? Like, do we add this to the list of all the things we're supposed to be tracking? And I don't know that we're quite ready for that place of we should

all be concerned about it. But certainly, when I was seeing 30 patients day, about a third of them, had vaginitis and had these problems. So at least among the patients that I was seeing, about a third of them need to pay attention to this. And the way that they were treated was totally wrong. They were treated with recurrent antibiotics. And what we've learned was it's not about just killing the bacteria that's dominant or killing the yeast that are there. It's about the terrain. So it's about getting the vagina to a place where it's in a state of balance. No. Are all of these microbiomes in our body related? Like I know we have the oral microbiome.

We have the gut microbiome. I believe we have a skin microbiome as well. And then we have our vaginal microbiome. Do we have more than that? And are they all connected to each other? Yeah, the connectivity is still getting worked out. But there are so many places where you've got a microbiome. You know, you've got it pretty much any mucosal surface.

So not just your mouth, but your eyes, your ears, your armpits, your groin. your groin, not just your vagina, but the vulva. So there's, you know, bacterial species, I think 10% human cells and like 90%. I know. I hate it. It's so gross. It's so gross to just picture these little bugs. Existentially is so weird.

So there's all these different microbiomes that are in a state of synergy, hopefully in your body. The way that they talk to each other, I don't know that we really understand that. It's so crazy to me how early we are in the research for all these things. Even like gut microbiome, which has become a little bit of a buzzword online, we've only known about it for like a few decades, right? And it's just crazy that it's so important. It's important for our mental health. It's important for how many nutrients we get from our food. It's important for our energy, all these different things. And we like just discovered it. Yeah. I mean, there was a lot of knowledge about bacteria and how it got disrupted by antibiotics or you get food poisoning and how that affects your microbiome. So you're right,

we're still at the learning to crawl stage when it comes to the microbiome. We know the most about the gut. How that translates into health is still the piece that is getting worked out. The level of complexity of the microbiome is staggering. And so it's taken a lot of specialized tools to be able to manage that complexity and to be able to make statements that are more helpful on a person-by-person basis. There seems to be a feeling that our gut microbiomes, and maybe there's just straightforwardly research on this, have gotten worse over time because of antibiotics and the foods we're eating and all these different things. And that's one of the reasons we're having so many more issues in our health these days. Is that true for the vaginal microbiome too? Has that gotten worse over time

because of our environmental factors, what we're eating, etc. There's a big difference between the microbiome of the gut and the microbiome of the vagina. In the gut, you want as much diversity as possible. And what you're describing with our food supply, with glyphosate, with the toxins we're exposed to, with the use of antibiotics, is that the diversity declines in the gut. And if you have more of what I think of as like the Homer Simpson bacteria, if you've got dysbiosis and imbalance of the good and the bad bacteria, that's kind of a simplified way of thinking about it. That leads to problems. Wait, is this because Homer Simpson is unbalanced?

Well, meaning that when you have bacteria that are not as intelligent and supportive. Are we criticizing Homer Simpson here? A little bit, yeah. That's fine. I mean, do you have a better metaphor? I mean, I'm open to other analogies. kids, it's also like, would those bacteria, like, thrive more on bad foods, even? Yes. So they like their pink donuts with the sprinkles. Yeah, totally. Totally. And they make you crave it more.

And they extract so many calories from the food that you eat. Okay. So when we have these like Homer Simpson bacteria in abundance, that's going to create these negative downstream effects. That's right. So in our guts, we want a lot of different types of bacteria. We're looking for really diversity over all else, essentially. Well, we want diversity. and we want a healthy balance of the type of bacteria that really support nutritional status

that really support with making things like short-changing fatty acids, help you with the immune system. So these benevolent bacteria, mostly bacteria, that supports you. The vagina is totally different. You don't want diversity. Diversity is actually associated with disease and more vaginitis. You want the focus to be on lactobacillus crispotum. So two different microbiomes, two totally different organizing principles.

So gut microbiome, we want diversity. We do not want diversity in the vagina. I want to ask a question, and I want to be careful about how I ask it. But when you have new sexual partners, does that introduce different bacterial species? We think so. So if somebody has a lot of diverse sexual partners, would that be bad for their vaginal microbiome? I don't know the answer. I mean, I'm thinking about how to you study that. So you could determine the exposure to number of sex partners, and then you could look at the vaginal microbiome. One of the pieces that's a little bit tricky is that it depends on if semen is involved. So in the vagina, we don't just want lactobacillusicrosbottum. We also want

pH to be pretty low. We want it to be acidic. Seamen is basic, so it tends to raise the pH, and it tends to make it more likely that you have overgrowth of Gardnerella, which is bacterial vachinosis. It might be good for the gut microbiome to have multiple partners and less good for the vagina. That's what I'd hypothesize, and I'd have to fact check that. Wait, so is the semen thing why whenever I've had new sexual partners, I feel like I instantly get like a yeast infection, a UTI, or both? Is there a scientific reason for that? There can be. Those can be related and they can also be separate. So one of the things about a new sex partner, I mean, it depends on if you're exposed to semen or not. So the pH change could be

associated with recurrent bacterial infections. If you have a change in what you're eating, like for instance, if you're consuming more sugar or you're having more carbs with your new sex partner. Like we're going out on fun dates and eating dessert together. Maybe you're drinking more. All of those things could be associated with more yeast overgrowth, which is mostly coming from the gut and then kind of spilling over into the vagina. And then separate from that, but also related, is bladder infections. The way I was taught about this is that if you don't pee right after you have sex, you're more likely to grow particular bacteria like E. coli, which is responsible for about 95% of bladder infections. Some of that's been disproven and lactobacillus

crospatum, again, the big defender of the vagina might also help with preventing recurrent bladder infections. Wait, I cannot tell you how many nights I have had sex and then my partner has like fallen asleep and I've just been like laying awake chugging water being like it is a rule you cannot go to sleep until you have peed. Is that not true? Well, I still think you need to pee. Okay. But it's not the total story. It makes me so angry. Like, I literally just sit there and it, like, ruins the good vibes of sex because I'm just like, you get to sleep and I don't. I know. I know. There's like this gender difference that is totally unfair. Okay. We're going to get into a lot of different stuff about the vaginal microbiome, but also women's health in general. But we asked if you

could prepare two truths and a lie for me. So I would love to do that if you have that. Okay, I've got three ideas to share with you, and you're going to tell me which two are truths and which ones lie. So, number one, you need for your vagina to be in the top 1% in order to deserve oral sex. Number two, when you go through perimenopause, which can start at 35, 40, you don't have to care about elicotum anymore. Number three, when you bathe, you need to care. get in there and scrub your vulva and scrub your vagina and get it really clean so that it smells like perfume. I feel like there's two lies there and a truth. Like, okay, you do not need to be in the top 1% of your vaginal bacteria to enjoy oral sex. I certainly do not think you're supposed to

wash your vagina that much. That's right. It's like a self-cleaning oven. It's self-cleaning. So those are both lies. Do I have two lies and a truth? You're right. You try to. You try to. to trick me? I kind of did. But you are so on your toes. I'm so on my toes. Okay, so let's talk about the washing thing because I actually do think

that this is something that we're told very mixed messages about. How much should we be washing our vagina and what is the impact on our vaginal microbiome of washing our vaginas? There's a spectrum here. And on one end is people who maybe don't bathe that much or don't have the opportunity to bathe.

And then on the other end of the spectrum is people who douche and who use other products to try to clean the vagina. And we don't want either one of those extremes. When I was growing up, douching was actually popular, and it never made sense to me. You know, especially as I started to study the female body, and it just seemed like, wait, you're taking all of this bacteria that's part of the vaginal microbiome. You're sending it up through the cervix into the use. uterus. How is that a good idea? It's not. So duching is not a good idea. I feel like we should just

put the nail in that coffin. But then there's this cleaning process that I think a lot of women do, like before they go on a date or before they have sex. And there's almost like an expectation that the female genitalia shouldn't smell like genitalia. Now, there is the healthy smell of an L. Crosbottum dominant vagina. And then there is a less healthy smell of a vagina that's not dominant in L. Crosbottom. So I think the way to solve that is to support the dominance of L. Crosbottom and not to scrub away any of these other bacteria that you're trying to get rid of. I have so many questions. Ashton Coucher and Milakunas famously talked about like they don't bathe themselves or their children that much because I think it was them. Maybe I could have the wrong

celebrity here, but I feel like it was them. And they said because they wanted their bacteria to thrive on their body. Is there a limit to that? Is that doctor endorsed? So it's not quite as simple as you need to wash away your bacteria or not wash away your bacteria. It's more, what are the healthy bacteria that you want to support on your skin, in your vagina, in your gut? I imagine that bathing does have an effect on the microbiome, especially of your skin. But I don't know that we've really identified exactly what the right frequency is. So I think there is such a thing as bathing too much and drying out your skin and affecting the microbiome negatively. But I'm not sure what that rate is. For people, for instance, who don't bathe as often and they've got more

body odor. That's usually anaerobic bacteria, like especially in armpits and other places. That we want to wash away, especially if you like being around other people. But we don't want to do it too aggressively. Like, you have to find the right balance with it. And just to be super duper clear, like, are you washing the outside of your vulva? Are you washing your butt crack? Like, I just want to be super specific of how much soap are we using antibacterial soap, non-intybacterial soap, like, when you say we want to be careful with washing that area of our body, what does that actually look like? What I'm talking about is washing your butt crack.

I think that's a good idea because that's where your feces go and you've got a lot of bacteria. When it comes to the vulva in the vagina, I remember Amy Schumer talking about this, about like a little like a little kind of wipe. That's an idea. Is all that you need. Yeah. So I like to take baths. And I think the bath kind of takes care of it.

Because it's like soapy water. Soapy water a little, mm. But you're not getting up in there. You're not scrubbing. You're not scrubbing. Also, if somebody's going to finger us, do they need to wash their hands first? Is that a bad introduction of bacteria to our vaginal microbiome and potentially disruptive? Or does that not matter?

And it's like self-protective and it's fine. I would say before someone, you know, I've got two daughters. I'm probably going to mortify them, right? I would say, yeah, he should wash his hands. Like, I don't know where his hands have been. Yeah. And if someone defecated before they finger you, their hands are not going to be as clean if they didn't wash them.

I just think about like our hands are dirty as part of our body. Our hands are dirty. We're touching up all day long. They talk about how dog mouths are cleaner than human hands. You mentioned odors. So what is a good, healthy vaginal microbiome? by them smell like in sort of layman's terms? And then what are some indicators that it might not be so healthy? Again, there's a spectrum here. So I can tell you as a gynecologist, he's taking care of a lot of

vaginas and vulvas. There's the normal smell of the female vagina and vulva. It's not yeasty and it's not fishy. The yeasty and the fishy usually relate to not having l crisp bottom as the dominant species and having an imbalance. So having too much gardenerella, which creates the, I hate to even use the word fishy, but it creates the fishy smell

and it's associated with the higher pH and it can cause discharge like this gray discharge. And it doesn't smell yeasty. It's hard to describe these smells. I feel like we need to scratch and sniff right now to sort of indicate what some of these differences are. But most women who have

experienced a yeast infection or bacterial infection, they know the difference between their normal vagina and what it smells like when they're yeasty and what it smells like when they've got BV. They do, but I think the main reason I'm asking is because a lot of women, which you pointed out, this is like what led to the rise of duching in the first place, feel embarrassed about very normal vaginal smells. And that's what I want to undo because I think some of us grow up in a culture that assumes that we should have zero smells whatsoever. And that is not healthy and not right. There's shame wrapped around the normal smell of the vagina and the vulva. And that's what I want to change. Are there other indicators that our bacteria are out of balance

in our vaginal microbiome? Is that a test that we should take if we suspect it? Are there things we can look for? There's the smell indicator. Yeah, I would say smell discharge. discomfort, you know, used infections can make you feel swollen and itchy. There's pH. So normally, the vagina has a pH of about 4, 4.5. So you can use pH paper to see what your discharge pH is. Bacterial vaginosis, again, is basic, so it's not acidic. So those are some of the best indicators. So women who have bacterial vaginosis have a higher rate of STIs, sexually transmitted infections. we think that it's related to lactobacillus crospatum, that if you don't have this defense system

that lactobacillus crospotum provides, you're more vulnerable to sexually transmitted infections. Oh, wow. Well, and then Brian Johnson said that Kate got a test and got 100 out of 100 on it. Right. What tests is that? Do you know?

So there's a couple of different tests out there. I'm not paid by any of these companies. there's the Evie vaginal microbiome test. There's another one called Tiny something, which I think is what he used with Kate. Hopefully Kate used for herself

as we're talking about the objectification of all of this. I do like, I think she's, from the vibes I get, I feel like she's a willing participant in this game, but I really hope she is.

You know what I mean? I hope so too. I mean, it's tricky because he's a very wealthy and powerful man. Yeah. He wields a lot of influence. Yeah.

And so I hope that she's got utter sovereignty in that decision, but it's not completely clear to me. Are these tests accurate? Do you think they're up to the place where you would recommend people get them if they're curious about their vaginal microbiome health? I think it's a place to start. Evie has been around a long time. You can also do some basic testing, like a culture with a gynecologist. I think that is usually less helpful. All right. We're going to play a game called myth or fact. So I have a bunch of statements I'm going to make about the vaginal microbiome and some women's health stuff in general. And I would love to know if it's a

myth or fact and why. Your vaginal microbiome can make sex better or worse. True. And in what way? It's indirect. So if you don't have the kind of community set up with Elkris bottom, you're more likely to have bacterial vaginosis. You're more likely to have yeast infections, more likely to have bladder infections, irritation and discomfort. So I think sex is better if L-crosbottom is dominant. pH balancing washes and wipes balance your pH.

No. They don't at all? There's an over-the-counter product that helps to change the pH of the vagina. And I think that lasts longer than a wipe or a wash. There's a lot of products that are these washes

and I don't think they work as well as like the refreshed product that goes up inside the vagina. But I think really, as someone who cares about enduring health, this is where L. Crosbottom is so much more important than just treating the symptom, like with a wipe or a wash or even refresh inside the vagina. Scented tampons impact your vaginal microbiome. I imagine they do. I don't know the data on it. The way that I think you would look at this is to understand what the chemicals are and the scented. tampons that are used? Are they thallates? Is it like a perfume? I think it's a synthetic perfume. I can't imagine that's good for the vaginal microbiome, but I don't know the data. It's also,

like, again, kind of gross because it's saying, oh, your vagina doesn't smell right. You need to add this additional smell to it to be acceptable in some way. That's right. And there's the shame around the normal healthy smell of the vagina and the vulva. There's also the shame around the normal smell of menstrual blood. This is one of those places where I talk to my daughters all the time about these things because I don't want them to have this internalized shame about normal function in their body. Scented tampons feel like they totally feed into that shame. Yeah, completely.

I mean, I was in my 30s before I wasn't passing tampon. Like they were drugs. You know what I mean? Like I was like doing a little secret drug deal to my friend. Oh my God. Thank you so much. I got a tampon. Right.

And that's crazy. Like when half the population is menstruating or pre or post menstrual, that's insane. No, we need to normalize it. I want to be able to walk into a public restroom and see someone who's using a menstrual cup and like washing it in the sink. Yeah. Like no shame. Okay.

So I have a question about that because tampons made the news a while back for having even organic tampons having all of these like I think it was like high levels of. dioxins and things like that, things that are scary to have enter your bloodstream. Is there a better or worse way to deal with menstrual blood? You're a leading gynaecologist. How do you approach this? How scared should we be? Yeah, this is one of those situations where I think you have to kind of rank order

how you want to live your life. I would say probably the healthiest thing is to use pads, like cotton pads. Was I wearing a lot of cotton pads when I was menstruating? No. It just was kind of messy and didn't work very well for travel. Tampons were a lot easier. I like to swim. So I think you have to find that intersection between what you prefer personally and also what's the healthiest.

Yeah, that's fair. I use period panties, which I absolutely love. Oh, I love period panties. But those also made the news a while back for like certain ones having high PIFO levels and stuff like that. I think minor, okay, I use the salt. brand, which they say they test for that, but I like them a lot. I actually feel like, I don't know if there's any research to this. I feel like when I wear period panties, I get less cramps than when I use tampons. That makes a lot of sense, actually. Well, I would

make sense? Because I imagine tampons disrupt the vaginal microbiome. We know about the dioxin exposure, for instance. So when you're putting a tampon inside the vagina, I think there's some inflammation associated with that. And inflammation can increase cramping. So that's a hypothesis, but I think period panties are a huge advance for women. I've been drinking element every single day for literally years. I usually use one packet a day, but I break it up and I kind of spike my water throughout the day. So it makes my water taste amazing and it helps me stay consistently hydrated, which for me means more energy, fewer headaches, and way clearer thinking. That's like probably the biggest difference I notice is

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If you're ready to experience a probiotic that actually works, go to CED.com slash Liz Moody and use code Liz Moody to get 25% off your first month. That is seed.com slash Liz Moody code Liz Moody. This is maybe speculative as well, but one of the ways the copper IUD works is by creating localized inflammation, right? And so I have so many friends who have the copper IUD and they have really heavy periods and really bad cramps. Could that be related? We do think that they're related.

So a couple of things about the copper IED, which, you know, unfortunately, there's not a lot of great contraceptive choices for women. And I think the copper IED is probably at the top of my list because it's as effective as getting your tubes died. It's got no hormones, no synthetic hormones. And the period of time that you feel like your periods are heavier and more crampy is usually about the first six months. So what I focus on with my patients, I'll put an IUD in. I'll do Reiki with her. Wow, you put the IUD in? Absolutely.

Oh my God. Thank you. If you put me on a pedestal in public for like 20 minutes to talk about something, I'd either talk about Taylor Swift or I'd talk about how we need pain management when we put IUDs in because it's the most pain I've ever been in my entire life. And they told me to take an Advil and to go home. I didn't even have Zach come with me because they were like, it's just going to be really chill. I was in the back of a taxi in New York City, like writhing in pain. Totally.

It was awful. You do Reiki while you do it? Absolutely. That's so amazing. Thank you on behalf of women. Carry on. What I try to do with my patients is to create an environment for the IUD so that it can really work and not like fight it.

I use an herbal supplement called Slow Flow, the first six months that a woman is cycling with a copper IE. and it really works to reduce blood flow. Because a lot of women have low iron, something like 20% or more in the U.S. have low iron. And even if they're not anemic, they're losing so much of menstrual blood that they're not able to deliver oxygen to all over their tissues. Which feels important. Which is super important, especially the brain.

Yeah. If we can reduce the amount of blood flow with the copper IUD, I think that's a huge advantage. And then I'm not a big fan of popping ibuprofen. I think you want to work with the inflammation system. You want to use resolvers of inflammation. So what I typically do with the copper IUD is baby aspirin, omega-3s, like two to three grams a day. And I'm not a huge supplement van, but this is one place where it's helpful.

And then something called pro-resolving mediators that help you resolve. the inflammation that's in your uterus. So that's how you're meeting the IED in the middle to try to create a relationship so that it can work for you. You know, it can work up to 10 years. So you might want to establish that relationship to be really healthy at the beginning. What are pro-resolving mediators? So there's this guy at the Brigham in Boston, Charlie Sourhan, who discovered that when you take an ibuprofen and you look, at the inflammation cascade, you reduce the amplitude of the inflammation, but you actually block the resolution. So there's these little molecules that help you resolve inflammation. And some of us

don't make enough of them. And so we've got this kind of chronic low grade inflammation. You see that in women with endometriosis. You might see it in women with a copper IUD. and we want to do what we can to resolve the inflammation. So that's what these pro-resolving mediators do. They're over-the-counter. Would I just like Google pro-res, is that what it's called? PRMs. Some of the supplement companies call them specialized pro-resolving mediators.

So, yeah, that's how you find them. And would this be your protocol for cramps as well, if somebody's having really bad cramps? Yes. And we know that it makes a three is to make a big difference. So two to three grams a day. All cycle or just when you're cramping? Women do better when they've got sufficient omega-3s or balanced amazas, not just three, but six also in balance.

So I tend to give it all cycle long. We know that women who have lower omega-3 levels have more period cramping, more dysmenorrhea. Okay. So omega-3s and the pro-resolving mediators? And a baby aspirin. And a baby aspirin. Interesting. And the baby asked. And Reiki. Tell me about Reiki because you have been to pretty much every impressive school as far as I can tell. You're like if there is an impressive school, Sarah's graduated from it in some capacity. And Reiki feels a little bit more like out there, I think for a lot of people, including. I'm kind of a skeptic. I've had Reiki done to me though. And I was like, I felt amazing. But I'm like, girl, you're not touching me. Like how do I what is happening here? As somebody who's gone to like, John Hopkins. Harvard, MIT, can you make a case for Reiki for me?

It is becoming more quantifiable. I would say in the past, I felt just the way that you're describing. I was very skeptical, and I was like, okay, really? Like, you're going to wave your hands over my uterus, and it's going to make a difference. But I think there is something to energetic healing. There's randomized trials showing that. You can send healing to someone, and it changes outcomes. So this is a whole other topic that we should maybe talk about at a different time.

But I believe there is something to Reiki. How's your intuition, Liz? I don't know. I actually, if I'm being very honest, sometimes I struggle with what is my anxiety and what is my intuition. Yeah, that makes sense. Do you ever have a moment where you hear something so truthful that the hair on the back of your neck stands up? Yeah. Yeah, I have had those moments.

So that's what I'm talking about with energy, energy medicine, energy. transmissions. So is that the bulk of my work? No. Is it an important aspect and tool that we can use and leverage when needed like when an IUD is put in? I think it can be. Does it work on every woman? No. Yeah. Interesting. I'll get back into myth versus fact in a second. But I am just so interested in the way that you're approaching these things that 98% of the medical field is doing one way, like putting in an IUD and you have your own protocol for them. So is there anything else like that where you're kind of treating it in a really different way than standard practice of care. Everything.

I mean, the list is so long. Yeah. And I was an IUD crusader because I felt like way too many women were just put on birth control bills. And we had to find a way to take the form of contraception that has the highest satisfaction rate, the highest. And the lowest use rate, millennials have changed that, but the lowest use rate in my population of my generation of gen Xers. I've been writing about breast health, for instance, and I feel like we're totally wrong in how we approach it. So a woman has a, at baseline, 12.5% risk of developing breast cancer over her lifetime. And that alone is way too high.

That's crazy. I didn't know that. 12.5%. I have 10 friends, at least one of them, is it likely going to get breast cancer? No question. That's insane. It's totally insane. And what we do is we tell women to wait for it. Get a mammogram once a year after 40. And if we catch it, we'll catch it early and we'll do our best to try to improve your survival. The five-year survival is so much better now for breast cancer.

I think that's wrong. I think we should be offering genetic testing. I think we should be super clear in our culture about some of the things that you can do to reduce your risk of breast cancer? Like, eating your vegetables when you're an adolescent makes a huge difference. When you're an adolescent specifically? Yes. Oh, no. Bad for me. Right. I know. I was eating a lot of. I was eating a lot of fruity pebbles and bread. Same. Pasta. Yeah. That's interesting. So why then specifically, is that because you're going through hormonal changes at that time that impact your breast cancer risk down the line? Not sure we know. It's something about the way

that the polyphenols and the other fabulous nutrients that are in vegetables, the way it interacts with your stem cells, the way that it sets you up in terms of your trajectory with your health. I've given a lot of talks on breast cancer risk reduction. When I learned that one, I was like, oh, I'm screwed. Yeah. It's like great for everybody out there who's like a parent maybe and you're like really no you're broccoli kid. But yeah, but your kids don't want. Yeah. Like how do you convince them? I have a fantasy. I'm not a parent. which you'll be able to tell by the next thing that I'm going to say. But I have a fantasy of being like, broccoli is a special treat and kind of getting them like,

oh my gosh, we get our broccoli right now. And then they don't know because they only know the world I've created for them. It doesn't work. Okay. The problem is the rest of the world outside of that. That's true. If somebody is listening and they're a millennial woman, what are three things they could do to reduce their breast cancer risk? Number one, manage your blood sugar.

We're living in an era of so much democratization of health data. If you use a continuous glucose monitor, if you're open to that and you do it for two to four weeks and you get a sense of your individual personalized response to the foods that you're eating, it can be so helpful. Because we know from a study that was published by Michael Snyder at Stanford, people who are told they don't have pre-diabetes or diabetes. about 15% of them have pre-diabetes, and about 2% of them have diabetes. And so I found that using a continuous glucose monitor in my patients helps them identify in real time these outsized glucose swings

that they can then prevent with the way that they eat or the way they combine foods. And is it really that different person to person? It's pretty different. Okay, because I feel like there's like, you know, if you're going to eat carbs, try to eat them with some protein and some fat. And I feel like there's kind of these like don't, you know, eat simple sugars, et cetera, et cetera. But there's, it's really unique person to person.

It's both. Okay. So I think there's some ground rules that you talk about that I think are super helpful. I found, for instance, that when I was looking at my glucose 10 years ago, protein powders were spiking my glucose way higher than I ever expected. And these are protein powders with very. little added sugar, like zero added sugar, two grams of added sugar. I thought I was making these super healthy protein shakes with broccoli, broccoli sprouts and avocado and all these things. I was also having a reaction to legumes, so like chickpeas. There were some things that were not surprising,

like potatoes, sweet potatoes, any form of potato, purple potatoes. All of those things were spiking my glucose up to diabetes levels. Oh, wow. So it made a big difference to be able to see my individual response. And I find that that's often the case with my patients. Okay, so that's thing one. Thing two. There's some things that are hard to manage.

Like, for instance, I've got an increased risk of breast cancer. My risk is about one in three instead of one in eight. And there's a couple of reasons for that one is I've got a gene mutation called check two. Another reason is that I had my first kid. after age 30. So you can't do much about that. Wait, so if you have kids later, it increases your risk of breast cancer. It does. But I've also read research that if you have kids later, you live longer. There's research that shows that if you have kids after 35, you're more likely to live long.

Well, both can be true because breast cancer isn't as deadly as other things like cardiovascular disease. So let me turn this into a tip. The tip is if you're someone who started your period really early, like before age 11, I started at 10. And if you decide to have kids, you have your kids after age 30. That makes the risk of breast cancer higher. And I would say you need to pay more attention. So what do you do? Here's the third tip.

Do the Tire Cusick score. So it's an online calculator. Maybe we can link to it in the show notes. And it allows you to look at what your lifetime risk is of breast cancer. If your score is 20% or higher, then you qualify for additional surveillance, like a MRI alternating with a- Like your insurance would pay for that? Yes. Okay.

Yes. So calculating your risk score, I think, is really helpful and it can be empowering because otherwise women just sort of have this watch and wait situation with breast cancer. And I just don't think that's the right approach. Does having children generally impact your risk versus not having children? Yes. So having a period of time where you're not ovulating is thought to reduce the risk. It also reduced the risk of ovarian cancer. So some of it depends on how many years you have of what the research field calls incessant ovulation. It does feel incestant. I'm like, oh my God, again.

Jesus. Totally. So nine months without ovulation does seem to decrease. breast cancer risk. And no birth controls actually stop ovulation, right? They just stop the egg from being fertilized or do some birth control stop ovulation? No, they stop ovulation. So would that impact breast cancer risk? So that's a little bit more complicated. It's not quite as simple as this reduces your risk. What we know with the birth control pill is that it reduces ovarian cancer risk. So this incestine ovulation thing is mostly related to ovarian cancer. We think that the birth control pill slightly increases the risk of breast cancer. It's modest, but the best, largest studies looking prospectively over decades show that a very small increased risk of breast

cancer is associated with the birth control pill. Which then maybe you want to pay attention to all these other things that we're talking about a little bit more. What I do like about your work and how you talk about this stuff, is it's not like, oh, this is scary, this is bad. Like, watch out. It's like, you're a real person living in the real world. Here's information. Here's how we're going to balance our priorities, our goals, our risk factors, etc. That's right. Speaking of inflammation, would you treat something like endometriosis or PMOS, which used to be PCOS differently than other doctors might? Oh, for sure. How do you approach those? So I think of it inometriosis as not an immune disease. It's not a classical autoimmune disease. It's not like a type of one diet.

diabetes or lupus or multiple sclerosis or Hashimoto's. It's a situation where the immune system is attacking the female body. So you have these implants that grow in various places, usually the ovaries, sometimes the bowel, back of the uterus. And first of all, I believe women when they talk about being. And I wish that wasn't such an important statement, but it most certainly is. I tend to treat an ametriosis with working with hormones. So there's some debate here, but there are some nutrition, nutrient-based strategies for managing estradial levels because we know estradial, the primary estrogen, most potent estrogen of the reproductive ears, stimulates endometriosis tissue.

So we think that if you reduce the estradial levels, and I try to do that with nutrients, that can make a difference. So what nutrients would reduce estrogenial levels? So there's a couple of different products that I use. There's one called Axis Endo, and it has a lot of flax lichnins in it. So that's one strategy. On the more pharmaceutical side that reproductive endocrinologists use, they tend to use things like Lupron, which just shuts down the production of esterone. and progesterone. I use low-dose naltrexone. It's an immune modulator. So I usually start at 1.5 milligrams, slowly get up to 4.5 to 5 milligrams. And that's been shown to be very helpful. I do genetic testing in my patients with endometriosis and PMOS to look at their cellular pathways so that we can try to optimize the function of those. So that includes looking at detoxification,

inflammatory tone. How do we reduce the inflammation to a point where it's less likely to cause pain and discomfort and swelling in the pelvis and elsewhere? I use natural progesterone. I don't like to use synthetic progestins. Most women with endometriosis will have a diagnostic laparoscopy, maybe they'll have treatment if they've got endometriosis. Which is when they like scrape out. Scrape or burn, laser. Yeah. And then afterwards, they often get started on a birth control pill. If they're trying to get pregnant, they get started on progesterone or progestin. And we know that progestones, which are synthetic forms of progesterone, can increase the risk of breast cancer. So I only use bioidentical progesterone in my endometriosis patients.

Generally, with endo, I like for a patient to be seeing an expert, you know, someone who's just really current with all of the conventional approach to endometriosis. So I've got someone in L.A., for instance, that I refer to. But she's not integrative. And so I think the two of us together can provide a level of care that, you know, don't otherwise get. We're trying to prevent the surgery. So what I like to do is to have kind of these daily practices that are in place, some of the things that I've mentioned already, so that you don't need the surgery. To me, that's the ideal. Okay. We're back to myth versus fact. Boric acid is

like a cleanse for your vaginal microbiome. Truth-ish. Okay. So I don't think the vaginal microbiome needs a cleanse. Okay. For women who've got recurrent yeast infections, I used to treat with boric acid depositories, you know, once they went through diphlucain, flucanazol, and maybe monostat and other treatments. But that's the way I used to treat it before we knew about lactobacillus crisp bottom. So now where boric acid kind of fits into things, now that we know about lactobacillus crisp bottom, I would say let's support the dominance of lactobacillus crisp bottom first, see if we can prevent recurrent yeast infections, and only if we can't, then consider boric acid. And like you feel like the research pretty much points to that we can.

Yes. At this point. And lactobacillus crisp bottom, is that a suppository? How are we putting that into our vaginal microbiome? Yeah, there's a couple of companies that have a product. And I always like to give a couple of options. I used to be on the scientific advisory board for Seed, so let me disclose that. And they supported the randomized trial that I was part of looking at the establishment of lactobacillus crisp bottom in women. So CEDA's product called VSO1, and it's a pill that you put in the vagina. And you treat yourself a few times over a month, usually at night, and then you have like a maintenance phase after that.

And I find that that works really well. It worked well in the randomized trial. 90% of women were able to establish a little cross bottom dominance, whereas in the placebo group, only 11%. And for right now, is that something that you would recommend if you are dealing with these sort of recurrent issues versus like every woman should be supplementing vaginally with this symbiotic, probiotic? So I would recommend it if you have recurrent vaginitis.

And if you're a woman who's over 40 who's got vaginal dryness and it feels like topical estrogen, local estrogen, or DHA isn't doing the trick, then I would say do the L-cris bottom symbiotic and then retry the estrogen or the DHA. When I used to get yeast infections when I was in my 20s, I would get a tampon and put it in yogurt and put it up my vagina. Is that terrible? Did you just like shiver internally a little bit or is that? Well, like food, like I go to the supermarket, get yogurt, dip the tampon in and then put it up there. I'm not aware of any randomized trials. Tampons with yogurt. But what I mostly feel is, is so much love and compassion for a woman in her 20s trying to figure out how do you solve this problem. Yeah. I do too. I feel a lot of love. and compassion for my 20-year-old self.

Cranberry juice prevents UTIs. Maybe a little bit. Okay. I drank a lot of that in my 20s too. Yeah, right. Is there some mechanism there? I don't know the mechanism off the top of my head, but there's some modest data that it could be helpful.

Tight leggings cause vaginal infections. I don't think so. I say you've got synthetic underwear and you've got synthetic leggings on. Your microbiome is not going to be super happy with that. So I don't think we're meant to wear really tight leggings and tight, fake plastic underwear. I'm not going to say that it causes faginitis, but I don't think it makes it better. Here's something I do that I do think you'll be proud of is I sleep naked.

I sleep without underwear on. Can you give a PSA for sleeping without underwear on? Because I think a lot of women still sleep with underwear on. The vulva and vagina needs a break. and it's really good for the microbiome to just be able to interact with air without sort of all these things that have been introduced over the past 100 years.

You know, my Greek grandmother was not wearing skim's underwear or a skim thong, right? Yeah. She had probably those old, I didn't ever saw them. Yeah, she had bloomer. She had like cotton. Yeah. And I don't think, I mean, I don't know,

but I don't think she was wearing underwear when she slept at night. Let's bring it back. Let's bring it back. Are thongs not recommended by you as a gynecologist, or do you think they're fine? I think they're fine once in a while.

This gets to the question of, like, how rigid do you want to be about your life? Do you want to be like Brian Johnson? Or do you want to have more fun and, like, occasionally wear a thong that she think is really cute? I want to have fun.

I used to be a thong girl. Now I cannot get over the idea that there's just this little string of fabric just like going up and down in my butthole. You know what I mean? I just think it was so cute. But now I'm like, hey, that's like a lot of butthole. To me, this is about sovereignty. Like, how do you want to feel in your body? Let women wear the underwear that they want to wear. Amen. Yeah. Antibiotics wreck your vaginal microbiome. So they tend to get rid of all cross bottom.

So antibiotics, just to be super clear, we've kind of heard they're having this impact. on our gut microbiome at this point. Are they having impacts on microbiomes all over our body? Yes. Our vagina, our skin, our oral, our eyes, all of that? So we know less about the effect

on other microbiomes, but yes, it depends on the antibiotic that you take. So I've been traveling to Mexico and I just took an antibiotic for Giardia. So it depends on which you take. You know, sometimes it kills gram-negative bacteria.

Sometimes it kills anaerobes. like Gardnerella, sometimes it kills gram positive bacteria. But generally, if we focus on the vagina, after you take antibiotics, you want to repopulate with Alcrisbottom. Okay. So you want to, that is a time you would want to do one of these supplements that we talked about. Yes. Are you a fan, though, of treating something like a UTI with an antibiotic?

Is that important to do? Or would you be like, just try putting L.C. bottom up there and that might help. Once you have a bladder infection, I think you have to treat it. You have to treat it with antibiotics. Especially as you get older and there's more risk associated with it. Perimenopause and menopause wreck your vaginal microbiome. I wouldn't say they wreck. I would say they change, they influence. So we know that in perimenopause, what happens initially is that your estrogen fluctuates wildly and then it goes down in the second half of perimenopause. In menopause, generally your estrogen's much lower. Even if you're on horse, you're on horse.

hormone therapy, your levels are about a quarter of what they used to be. Estrogen helps to keep Elchrosbottom as the bouncer in the vagina, the immune modulator. And so when you have less estrogen, you're less likely to have Elchristotum dominance. So I wouldn't say it wrecks your microbiome, but your need for a symbiotic to help the microbiome is higher. So would you say if somebody is in perimenopause, that might also be a time they'd want to regularly consider supplementing in this way? Yes. I mean, we just talked about, do all women need this? And I don't think we're there yet in terms of data. So I think premenopausal women who've got vaginitis benefit from Elkris bottom. Paraneposal women who've got vaginal dryness or vaginal symptoms, vulvar symptoms that they can't

resolve with estrogen, they should try the Elchrist bottom as a lot. the foundational layer. I know a lot of the work you do is about perimenopause, menopause. I'm so scared of perimenopause now. Like, I feel like it was not part of my cultural consciousness at all for a very long time. And I was like, okay, great. I went through puberty. Now I won't worry about this again until my mid-50s when I go through menopause. And then this cultural conversation happened, which is so important. And I'm so glad so many women are being seen, heard, researched, et cetera. And I feel like I'm now like, I'm in my 30s and I'm like on the look out for these like symptoms in my body. I'm sure my 40s are going to be ruined. It's very

disheartening. Do you have any? I don't know what the question is. Can you make me feel better about that? I absolutely can. So what I know about you, Liz, and I met you, didn't we meet like 10 years ago? Yeah, like when I was a little baby editor. Yeah. And I know that you architect your life in a very particular way. Like you take really good care of yourself. Women who take good care of themselves, who know how to regulate their nervous system, who know how to eat, who know how to exercise and listen to their body, who don't do this cognitive override, they tend to go through perimenopause much more easily than women who've been all things to all people and living kind of from the neck up and not eating well. And maybe in a relationship where they're

not happy and they're not co-regulating each other, you don't have any of those things. Those are the women who tend to have the most symptoms. There's 100 plus symptoms. We get it like jammed down our throat everywhere we turn these days. The women who've got these lifestyle basics in place are the ones who have very little symptoms when they go through parietanepause and menopause. What about the greater like your ovaries are in organ and now your health is just going to be worse forever and you're going to be more in flame forever and you're going to get cancer. I hear all that. But then I also am like, well, women live longer than men and we, so I don't know. I don't know how to square that circle either. Do you feel like you take good care of your mitochondria?

Yeah, I actually feel like I do. I do. I'm like red lighting. I got my ulythine. I'm like doing my weight training. Yeah, I feel like these little guys are well taking care of in me. So in your heart cells, each of your cells have like 2,000 to 5,000 mitochondria. in your eggs, your egg cells, there's about a million mitochondria. And so the place that you feel a mitochondrial deficit or reckoning is often in your ovaries. When you take good care of your mitochondria through your lifestyle, I think it's much easier going through a barring menopause and menopause. I'm genuinely confused how Masterclass gets literally the absolute top people in every single field to teach every single one of their. classes. I use it when I want to learn things directly, like the cooking class from Thomas Keller has

all of the wisdom that you would normally have to go to culinary school for. But also, I'm being honest, this is like a use case I don't hear a lot of people talking about. I'll just watch it for entertainment when I want to do something that's far more interesting than scrolling. Christina Aguilera taught me to sing. Shan Boudrum's Art of Mastering's Art of Master's, Art of Master's, it's 10 out of 10. There's menopause classes with leading doctors. There's script writing with Mindy Kaling. Literally, you name it. They're on masterclass, and it is such a good way to get off your phone. but have something that's like not quite as long or hard to get into as a TV show or a movie and that it just keeps you entertained and interested.

And you are learning. There are over 200 classes from the world's best, all for just $10 a month when billed annually. And you get unlimited access to every class on the platform so you can learn at your own pace whenever you want on your phone, your computer, or even in audio mode like a podcast. If you're looking to stop scrolling and start consuming entertaining content that makes you feel excited and helps you learn. Masterclass is it. And the best part, every membership comes with a 30-day money-back guarantee so you can start learning risk-free. Masterclass keeps adding new classes so there has never been a better time to get in. Right now, as a listener of this show, you get at least 15%

off any annual membership at Masterclass.com slash Liz Moody. That's 15% off at Masterclass.com slash Liz Moody. Head to Masterclass.com slash Liz Moody to see the latest offer. Did you know that the average half life of caffeine is five hours, meaning if you drink a coffee or matcha at 3 p.m, you still have half of that caffeine in your system five hours later when you try to go to bed, which delays your melatonin release and it makes it harder to fall asleep and get deep sleep. But I also get slumpy in the afternoon, which is why it's a perfect time to reach for AG1. When I drink it, I feel instantly more awake with no jitters and no impact on my sleep later. AG1 is a foundational nutrition drink designed to support your whole body health. I think

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certainly nobody told me, starting around age 30, our mitochondria naturally become less efficient. More get damaged, more become sluggish, and over time that impacts your energy, your strength, your recovery, and your resilience. Most of us respond by pushing more. We're like noticing these things and we're adding in more protein.

We're trying to fix it with more supplements. We're trying to do harder workouts. And those things do help. But timelines research suggests that we also need to be supporting the cellular machinery underneath. And that is exactly what their supplement, Mitopure, does. It contains Erolithin A, which helps your body clear out damage mitochondria and support healthier ones so that your cells can produce energy more efficiently.

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Oh, I've never felt as good as I feel right now. I mean, I was much more of a people pleaser, like in my 20s and 30s. And more overfunctioning, didn't rest a lot, felt like I had to earn it, would push myself so hard with weightlifting and 10 gays and not sleeping enough. So I would say there are a lot of things I did when I was younger that were not self-storedship and now I care so much about self-storagehip on my term. not anyone else's. I also feel like, and this is fully me just with you as an influencer that I'm watching

on the internet, but I also feel like you're in this like couples, goals, relationship. Like, it is, I feel like I've watched like a little bit of a renaissance. I don't know. It's interesting. Like, I feel like you've changed many elements of your life in this phase of your life. That's absolutely true. Thank you for speaking of that. Yeah, he's, uh, your partner's very cute.

I totally agree. Well, I remember watching you when you were, how long would you spend? Like you, I remember you were in Berkeley. You would go to all these places and you would post these like travel guides for all these fun places. And I love the videos that you had with your husband. And I remember at that time thinking, I'm so happy for Liz. I don't have that. So I was married to someone for 20 plus years.

and it was a difficult marriage. And it took a long time. I didn't want to give up. So I did 10 years of couples therapy. We worked so hard to try to be more compatible. And we just weren't. And we would dysregulate each other regularly, have these terrible fights.

And we would have a rupture and we wouldn't repair it completely. And I think that was probably more of an accelerated aging factor than anything else. else in my life. Wait, that is so interesting. Your dysfunctional relationship could be having physical effects on your health. That is well demonstrated. That is like a basic factor of social longevity. That if you're in an unhappy marriage, it takes years off your life. It's like smoking. Very well proven. And then the reverse is true, the corollary, that if you're in a happy marriage where you have the inevitable rupture,

but you're able to repair abundantly and completely. That is so good for you. It's good for your cells. It's good for your psychobiology. And all of these things are utterly measurable. So when I was married and I was wearing my garment or my oar ring, my HRV was horrible. It was like in the teens and the 20s,

no matter what I did, no matter how elaborate the vacation or how long the vacation was, my glucose had an average of like 105 to 110. And when I got separated and divorced, all of my health measurements got better. That is crazy. That's crazy. It's not the reason. No, no, no.

Like you're not sitting there like, well, hon, my HRVs 27, time for divorce. But it is interesting if we're sitting there. And especially everything you said makes me think about the woman who's like, okay, like, I'm going to try to eat this meal. I'm going to try to do this workout. I'm going to try to fit in this meditation. Okay, I'm taking care of my kids. Okay, I'm taking care of my husband. Okay, I'm in couples therapy trying to fix this stuff. And you're trying to fix all this stuff. And it's like, I feel like a lot of what you're asking us to do is say like, what do I really need and how can I really take care of myself?

That's the place to start. You know, I think when when you feel overwhelmed by all the possibilities of lifestyle hacks that you could introduce, going back to the basic truth that your body is trying to share with you is so important. body literacy. Now, I overruled my own body literacy for decades, so I'm not saying that, you know, this is something that I've always done. This is relatively new. But I recognize in you, and I want to put you on the spot here, I feel like you've had body literacy the entire time I've known you. What do you think? What do you feel? What do you notice? What do I feel? I think that's interesting. I had a seizure when I was 19 and it caused this, like, host of PTSD and just this long thing. And I think that event really broke a sense of trust with my body.

And I've been intentionally trying to rebuild my relationship with my body ever since. But maybe because of that intentionality, I ended up in a better place for it. That's really beautiful. It makes a lot of sense. And I think at 19, that's just pivotal time as you're becoming an adult. Yeah. And there's you know, what I've seen taking care of women for the past 30 years is that that can be a common experience of painful periods, endometriosis, a miscarriage, a seizure, where you feel like this bidirectional relationship that you have between your mind and your body is not as trustworthy as you thought it was. Like your body's betraying you. Yes. Yeah. And then I do think there has to be this intentionality. I think I also had an ED and I think that impacted that certainly. But I think

there has to be this intentionality of like we're on the same team. How can we actually be in relationship here? Yeah. And then there's so much cultural programming that makes that dialogue so impossible? Impossible. Well, okay. So this is a question that I had. Women are told to worry about so much when it comes to their health. What's one thing that you think we are worrying about too much and what's one thing that you don't think we're worrying about enough? Well, it's easy for me to reach for the vagina here because we've been talking about it the whole time. I don't think we center the vagina as much as we should. And I think that's especially true for women once they're about 40. Between 35 and 40, there's usually some subtle changes, early perimenopause. The thing that I don't think we do

right right now is we wait until women have vaginal symptoms before we set up the right environment for them. Lacta Bacillus Crosbottom is part of that story. It's an emerging story, but it seems pretty powerful. Brian Johnson and his situation with Kate aside. So I think it's really important to, especially if you're someone who really loves pleasure and you love orgasm, and you love sex and sexual connection, and how it feeds your primary relationship, I think paying attention in the vagina is critical. Where do we put too much emphasis?

I would say beauty and aging. I look right now at women in their 20s, 30s, and 40s who are using fillers and Botox, and I'm not judging them, but I just, with what we know about detoxification and plastics and the pressure that those women feel to look a certain way is something that I would love to address. I just would love to normalize the 11. I would love to normalize these seams that we have on our faces that are so well earned. And there's a way that plastic surgery as sort of in dermatology procedures have made

women look more and more the same. Yes. And that worries me. Yeah. And like nobody's saying George Clooney's lines are unattractive. Like we are clearly capable of filing that into an attractive category because we do it for many, many men, although men are not completely immune. like I think Brad Pitt allegedly got a facelift and things like.

Like it is coming for them as well. But like there are people that we manage to find attractive. And also for years and years and years, we managed to find that attractive. And it's only when things you could buy came in that we were sold this sort of like, it must look like this or it is not attractive fantasy. I had a guest on this podcast who said that he thinks all women should be on HRT after 40 because of the anti-inflammatory effects?

Do you agree with that? No. I don't think all women need it. At all. What 100% of women need is a conversation about it. I know, but it is so hard to find informed people to have that conversation with. Millennials are changing that. Like the millennials are totally saying we are not putting up with this idea that 75% of women go through pariumenipause and don't get the treatment they need and deserve.

So I don't want to malign your guest, but I feel like this is one of those places where women need choices. And it's not as simple as hormones yes or no. It's also what dose, what formulation, what's the right fit for you? Can you start with progesterone if you've got sleep issues and a period that's closer together to see if that helps? So I think it's a much more nuanced conversation. And I think we're finally training. providers to be able to provide that nuanced conversation after a few decades of almost nothing. But you don't think it's like even in absence of symptoms for the long-term health effects, women should be adding these more than. Well, it does seem to reduce biological aging. And there's outcomes that we think are quite rigorous from randomized trials. Like, it does seem to prevent

subclinical atherosclerosis. So kind of that under the hood cardiovascular disease that women get in their 40s and 50s. It does seem to strengthen bones. It helps to increase muscle mass. It may help the brain when it's taken within five years of menopause. So there's all of these benefits, but there are also women who don't want to go on hormone therapy, who have their lifestyle dialed into a point where they may not need it. So I think the main thing is a conversation with a collaborative clinician who understands your values and can present the latest data so that you can make an informed decision. I feel like HRT though, I'm thinking about it almost in the same way as GLP ones these days,

whereas more and more research comes out about all these health benefits. I'm like, is this something we all should just be on in the same way we would take a fish oil every day? Like are the anti-cancer effects, are the heart health effects, are the anti-dementia effects such that there is some indication that we should all just be like using this as part of our daily regimen? I think a lot more women should be on it. HRT, not GLP-H-R-T. Yeah. But I would say the situation that's a little bit tricky is women who've got a small breast cancer, especially if they've got very dense breasts on mammograms. And we think in that situation that hormone therapy can grow the cancer if it's got estrogen receptors and or progesterone receptors.

So it's a nuanced conversation. You know, for some people, it's worth the risk. For people who've got hot flashes and night sweats and they can't sleep, hormone therapy can be hugely helpful. For women who are trying to prevent osteoporosis, women with history of eating disorders who haven't had the estrogen effects on their bones over their lifetime. Hormone therapy can be really helpful.

It can help with muscle mass and preventing sarcopenia. I wouldn't say 100% of women to take it. I have a few embarrassing questions that I would like to ask you. And I want to be very clear, I don't think these are embarrassing. And we love de-tabuifying things over here.

But that includes making sure other people are not embarrassed about this stuff. So can I see my OBGYN when I'm on my period or should I wait? Absolutely. And you're not grossed out by it? No. Make the timing convenient. So this is part of the shame of menstrual blood.

We feel like there's this week where you have your period and you're not supposed to go see your gynaecologist. No, that's not true. Does my vagina stay cleaner if I'm fully shaved in hairless? I don't think so. I actually think there's some argument for the hair evolved to prevent infections. So there's like that component of it. I like the anthropology argument. I'm not sure what kind of data we have on this.

But again, it feels like it's one of those situations where there's cultural conditioning to make us look like young girls. Yep. And I don't like that. I don't like that I don't think anybody talks about is like, have you seen the skincare videos online and they start by just dripping white goo on their face? And I'm like, you are subconsciously doing a. shot. Like that is what that is meant to appeal to is this vision that we subconsciously have from porn.

And I don't think anybody's talking about that. And I'm like, there's so many like little things we do that you're like, where did this come from and who was it designed to appeal to? And like, let's talk about that. That's right. How much daily discharge is normal? You've got such a good question. A teaspoon? That is more than a lot of people might think. Let's take it back to the normal menstrual cycle. So women who've got a normal natural menstrual cycle, the discharge is going to fluctuate throughout the cycle. So right around ovulation, you've got an increase in discharge that occurs. We're aware. Yes.

So most women have a sense of their baseline that they see on their underwear. They know if there's an increase or change in color or change in the smell. And it's not gross. Right. Do you get grossed out when you see vaginas in your practice of like, oh my gosh, there's so much discharge here, this is nasty? No. I mean, I look to see, is there a lack of lactobocinous crissolus? Is that why there's so much discharge? But you're never grossed out? Or is there a reason? No, I, you know, my job is to understand what are the obstacles to health? Why am I having pain during sex even when I'm turned on? Is something wrong with me?

Pain during sex, you know, as a gynecologist, what I'm thinking about first is, is there a condition or a biological reason? for the pain? Is there too much inflammation? Is there endometriosis? That's kind of the classic thing that we think about with dysperonia. Is it that the vagina doesn't have lactobacillus crisp bottom? Or it's the tissue's too thin and it causes irritation. So I would say if you've got this comfort or pain with sex, find a trusted gynecologist who can investigate it with you. Now the last thing we're going to do is just a quick speed round of one thing. And I'm going to ask you a bunch of questions and you're going to share one thing for them. What's one thing that we should do before, during, or after sex to make it better?

Besides orgasm. Well, do you have any hot tips for that? Yeah. Like, explore your body. Like, the clitoral nerve was not fully mapped until March of 2026. What? Like, it is the least studied organ. In the entire human body.

Yes. So I think orgasm is the most important. Yeah. Yeah. And explore your body is your hot tip for that because scientists just started doing so. Yeah. And don't trust, don't outsource it to your partner. Yeah.

I think that's fair. What's one thing that we should do after we take antibiotics? And we know, so if you take antibiotics, that might be a time to consider doing the vaginal probiotic. But is there anything we should be like eating, doing otherwise after we do If you have a healthy gut, I think it's a good time to recommit to fermented vegetables. We used to think about probiotics as seeding the gut. We don't think about it that way anymore. We think about it more as a signaling molecule, but I think it can be helpful to kind of signal

your way back to a healthy microbiome. What's one thing we should do to have a better period? Omega-3s. What's one thing we should do when we start sleeping with a new partner? Get tested for STIs and make sure. that El Crosbottis is there as a bouncer and immune modulator. My mom drilled into me from being so young to do SDI tests and then also demand any new sexual partners had it. And so I was like, you know, I was a college student who watched a lot of sex in the

city. So I was out there having fun. But like every person I was like, show me. Show me your SDI testing. And I was very proud of myself for that. What's one thing you wish every woman trying to conceive would do? Know your methylation status. What's that? doing genetic testing, looking not just at MTHFR, but looking at 12 different SNPs, single nucleotideopolymorphisms, associated with the way that you methylate in the body. So we know that you're supposed to take folic acid, like that's part of the party line in obstetrician gynecology offices. You're supposed to do that for three months before you conceive. Knowing your methylation status helps us identify who would benefit more from methylated fully. Interesting. Is there any reason why we shouldn't all just take methylated B vitamins?

Well, some people don't need them. And are they more expensive? Yes. Okay. So like if you don't need them, you don't need to pay for that. I have the MTAHFR though. It feels like everybody has it. Do you know how common it is? Something is like 57%. Yeah, I feel like everybody I know is like, yeah, I don't know the MTAHFR. What's one thing you wish everyone in perimenopause would do? Track your HRV. Get a sense of what's going on with your nervous system. And look at perimenopause as initiation. something that's happening to you. What does that mean? Tell me about both of those a little bit more. I feel like women are especially wired for awakening and for deepening consciousness through their late 30s, 40s, and 50s. And a lot of the symptoms, I think, call us to look at our environment and how we're interacting with it and to develop these capacities for consciousness and a different way of interacting with the world. Wait, that's the single loveliest thing I've ever heard about paramedopause. That it's an invitation.

It's an invitation. To a higher level of yourself. Yes. And then why does HRV matter not to take you from grandiose, beautiful thoughts down to numbers? But why should we be tracking that in perimenopause? Because a lot of women experience drift in perimenopause. it flies below the radar of the annual testing they get with their primary care provider. And so I think heart rate variability can tell you if you're running yourself into the ground.

So if that is low for your baseline, because it's individual for everybody, right? You're kind of figuring out what you are. And then if you're low for that, that might be assigned to take care of your nervous system, take care of yourself a little bit more. Not just nervous system, but I think it maps to psychobiology. I think it maps to your relationship. It maps to the purpose and meaning that you get for. from the work that you do. I think it's an important indicator of how much time you're spending in fight, flight, freeze, fawn.

Because that activates the sympathetic nervous system. Wait, I love that you said that so much because I just did what I kind of hate when people do where you're like, well, okay, so then you should throw in some meditation and throw in some acupuncture and you're like, or maybe you should look at these root systemic issues that are causing these things in the first place and evaluate if they need changes versus slapping more stuff to do on top of it. Totally. Yeah. Thank you for correcting me. What's one thing that any woman could do for free that would drastically change how they feel? Spend more time with your girlfriends. I love that. What's one thing if we had all of the money in the world that women could do that would drastically

change the way that they felt? Be of service. What's one popular supplement or product marketed to women that you think is a scam? I can only pick one. There's some supplements that I think are really important. But I would say that we've talked about how paramedopause has become more a part of our cultural conversation. And I feel like supplement companies are racing to offer products to pariaminopause, to treat pari menopause. And I don't think that's the right approach. I think it's more of an inside job. What's your hottest take on women's health? So I've changed my mind about bone density. I was taught to check bone density in women at 65. I think we should be checking way earlier than that.

So peak bone mass, we used to think, was at 30 to 35. It's actually 20. And so I think we need to be paying attention, especially in the era of GLP ones, much sooner and earlier to bone density, especially women with eating disorders, which is probably three quarters of my patients. And what do we do? I got diagnosed with osteopenia, which shock me. And then I got these really mixed messages in my research on calcium and I was and then

weighted vests and all the I feel so confused. I feel more confused than before I knew about it. So what should we be doing if we're worried about our bone density? I think the most proven are keeping your vitamin D at a healthy level. You're right. The data on calcium is really mixed. And then I would track estradiol levels to really make sure that they're at kind of a healthy floor for you. I've seen mixed data on weighted vests. I think lifting heavy is more effective. I do that. And I've also started jumping.

I don't know. I think that's great. Okay. I love it. Get the little platform out at the gym and I'm trying to go higher and higher and higher with my jumps. Amazing. Okay. Jumpbox?

Yeah. That's not. It seems scary, the really high ones, but we're working up to it. What is the most underrated, boring thing that actually works? Morning Light. Hmm. You're a circ walk, girly? That's what we call it in this.

community. We go outside, do a little circwalk for 10 to 15 minutes in the morning. Yeah, a circwalk, but women need more. Oh. So women generally need about 20 to 30 minutes. Oh. So I can send my husband home and get some me time for the second half of my circuac. That's right. Okay. I like that. Why is that? Is that just because of our hormones? Our retina responds differently, but what works for men doesn't seem to work for women, which is usually the story. Yeah, that's always the story. And then where do you think the future? of women's health is going. Like we weren't talking about the vaginal microbiome. I mean, I feel like we literally just started talking about it. We certainly weren't talking about it 10 years ago.

What do you think we're going to be talking about in 10 or 20 or 50 years that we're going to be like, I can't believe we weren't talking about this back then? I think we're going to be talking about the list of ways that women were failed by mainstream medicine. And that list is so long, but it includes autoimmune disease. It includes thyroid dysfunction. It includes perimenopause menopause, which is turning slowly. It includes trauma, sexual trauma, depression. This message that we're supposed to be thin to look good and close. Given GLP-1s, I think in 10 to 20 years, we're going to see so many women with sarcopenia who are thin and maybe went on a GLP1 to lose 10 or 15 pounds when they were actually in a healthy weight to begin with. And now they've got

consequences to their mitochondria, to their bones, to their muscle mass. And it's really hard to dig out of that hole. Is it the antidote to that if somebody is taking JLP ones? Because there are all of these also like exciting health effects. Are you just like you must be eating protein and weight lifting? Yes. And tracking your muscle mass through like a Dexa scan or something A dexas scan or an body. I would say once a quarter. I think that should go with the prescription. What's one habit?

And this can be in the realm of everything we're talking about or something completely different that changed your life. Getting emotionally current with my partner every night. What does that look like? Checking in about our date, not in a weather report way, but like what's really on our heart. That's been profound. And you just like, when you're just like,

when you're laying in bed, you'll be like what's really going on or like a dinner or something like that. You have a habit of it. Or we go for a walk after dinner, which I think is a really great habit. I used to have pre-diabetes. So all these things that help with metabolism I'm a big fan of. But really intentional time together. And using our connection as service, like to support who he is in the world. He's a physician to support the changes that we want for our children.

and, you know, not just using our love and connection as some beautiful oasis, which it is, but using it to serve. I love that. I love that so much. I also just love that, like, you can meet that person and have that relationship at any point in your life. And I just think that is such a cool example that you're setting for that. And I don't know, it makes me really happy. It makes me really hopeful.

We love to leave listeners with one thing they can do immediately the second they turn off this podcast to begin to feel a different. So in the arena of women's health, what's one thing we could all do today? Lift heavy. Okay. Even if you're just going to plank, how long can you plank? How long can you hold a blank? I can do a minute. That's amazing.

Okay. So I would say one thing you could do today is do a minute and 10 seconds. Like keep trying to get that up there. How long can you hold a plank? About two minutes. Oh, my God. Really? Yeah.

Oh, I'm so impressed. Okay. So I'm going to get that up there. Okay. I'll work on it. I'm going to try a minute. 10 seconds today. I'll let you know how it goes. Sarah, this was so wonderful. If people want more from you, and I'm sure that they will, where can they find you? You can find me on substack. Sarah Zolmd.

at substack.com. I have been devouring your substack. Yeah. It's phenomenal. It's you just do such a good job. I mean, you did it in this episode as well of like taking these really hard to understand scientific concepts and saying like, okay, let's break it down. Here's the real science and here's how you actually apply this to your life. And here's how you should be thinking about it in the context of like you want to live a good life and be a whole person. That's the goal. Thank you for reading. Yeah, I've got a website, Sarah's all-MD.com, but I would say substack is where all the action is right now. You also have like 17 million books, so there's lots of places you can find her, but I would start with the substack. Thank you so much for everything that you shared with us today and everything

that you're doing for women's health generally. Thank you, Liz. Same back to you. That is all for this episode. Thank you so much for listening on Apple or watching on Spotify or YouTube. You can or follow so our next episodes get sent directly to your feed. If you like this episode, leave a comment or better yet, send it to a friend, a coworker, a parent, or somebody else that you think might love it. All right, I love you. Thank you so much for listening and I'll see you on the next episode of the Liz Moody podcast. Oh, just one more thing. It's the legal language. This podcast is presented solely for educational and entertainment purposes. It is not intended as a substitute for the advice of a physician, a psychotherapist, or any other qualified professional.

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