The Rich Roll Podcast - Decoding Women's Health: Dr. Elizabeth Poynor On Midlife Hormonal Changes, Interventions That Actually Work, & Why Medicine Left Women Behind

Episode Date: January 26, 2026

Dr. Elizabeth Poynor is a gynecologic oncologist, Chair of Women's Health at Atria Health Institute, and host of the podcast “Decoding Women's Health.” This conversation explores why women's health has been siloed for centuries, modern hormone therapy, the estrogen-brain connection, metabolic shifts, GLP-1s, and what partners need to understand about this transition. Underneath it all: generations of women have known what the medical literature is only now catching up to. Elizabeth is a vital voice. I hope this discussion reaches those who need it. Enjoy! Show notes + MORE Watch on YouTube Newsletter Sign-Up Today’s Sponsors: Go Brewing: Use the code Rich Roll for 15% OFF👉🏼https://www.gobrewing.com  Caraway Home: Save up to $190 on cookware sets + an additional 10% off with code RICHROLL👉🏼https://www.Carawayhome.com/RICHROLL   The Sprouting Company: Get 10% off + a free copy of “The Sprout Book” with code RICHROLL👉🏼https://www.thesproutingcompany.com/pages/richroll Rivian: Electric vehicles that keep the world adventurous forever👉🏼https://www.rivian.com  WHOOP: The all-new WHOOP 5.0 is here! Get your first month FREE👉🏼https://www.join.whoop.com/Roll Check out all of the amazing discounts from our Sponsors👉🏼https://www.richroll.com/sponsors   Find out more about Voicing Change Media at https://www.voicingchange.media and follow us @voicingchange

What is happening to women in their 30s, their 40s, and their 50s? What are the changes that are occurring? I don't feel like myself. I'm not the same person that I was. My energy level is in the same. Many times you get, oh, you're just getting older. And no, you're actually having real hormonal fluctuations and changes that we can actually help you with so that you do feel back to yourself.

Dr. Elizabeth Pointer is a gynaecologist, surgeon, and cancer specialist. A trailblazer in women's health. She also treats hormone-related issues and cancers. If there's something that has changed in how you feel, that's indicative that there's something changing in your body. And you need to get an answer to that. There are definitely answers. You don't have to feel like this. That agency to feel better and live longer and live healthier, no matter where you're starting from, is within everybody's grasp.

For midlife women, it's a pivotal time to make those decisions to approach lifestyle. I have this very positive outlook on midlife. This is like the beginning of the rest of your life. We are brought to you today by the wonderful folks at Go Brewing. A few years ago, there was this guy, his name's Joe Chura, and he called me up out of the blue and asked if I would speak at this event that he was hosting in Illinois called Go, which turned out to be this incredibly memorable weekend for me and for all of the attendees, because it was all about how to take inspired action.

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Your current specialty seems to be really focused on midlife hormonal health for women. Paint the picture of this transitionary period in a woman's life. We've known that fertility falls off between the ages of 35 and 40, right? We know that your measures of what we call oberian reserve or how the ovaries work actually falls off between the ages of 35 and 40. We know the fertility implications of that. We know that, okay, this is where. or maybe talk about IVF more and that type of thing. But we don't understand the other really important cardiac implications of that,

brain health implications of that, very importantly metabolic implications of that. So we've studied in what we call late reproductive years. So after your childbearing is complete, right, 35, it's really between 35 and 45, but that shift in ovarian reserve occurs between the ages of 35 and 40. So the ovaries start to taper off. They don't produce, the eggs that they produce are the obvious. circulatory cycles that you produce are not as good. The progesterone is not as high. The estrogen level is starting to fall a little bit maybe or become a little bit more erratic. So we know that

that impacts fertility, but we need to talk about how that impacts your brain health and your metabolic health and your cardiac health. So these are the years that really were very subtle changes will occur. And if you look in the medical literature, there's only like something like 60 papers published on the non-fertility aspects of the late reproductive years. So like just not very many papers published. But what we do know is that as the ovaries kind of fall off in their function, that's called ovarian aging or loss of ovarian reserve, that metabolic, very subtle metabolic changes can begin to occur.

Insulin resistance would begin to start during that time period. Lebedo may go off a little bit. bit. Mood actually may go off a little bit, a little irritability, a little bit of fatigue. They're all really subtle symptoms. And they're even before, do you even consider the word perimenopause, right? Because we think of perimenopause as a very erratic and large changes in big symptoms, right? But this is like, these are very subtle symptoms that are kind of whispering to you in a way. But during that time period, insulin resistance is starting, visceral fat is beginning to accumulate. And I always tell the story of some of my college friends and I were, unfortunately,

in a Dunkin' Donuts, right, waiting for a funeral to start. And we were all college athletes together. And we, and everyone says, you know, my waist is getting thicker. Yeah, I can't, like, I'm getting heavier. I can't lose this weight. And we were, like, in our 40s at that time. And then everybody starts lifting up their thing going, you know, I'm the gynecologist for the group, right?

Is that we call it the Princeton posse. I'm the gynecologist. Everybody starts lifting up and then Dunkin' Donuts. Everybody starts, like, yeah, what is this? got all this stuff here, I can't get rid of it. Well, that's like post-reproductive years, early changes in metabolism and insulin resistance. And then that just gets more profound as we transition into those, what we classically call the perimenopausal years, which are about 10 years before menopause. And brain health changes are occurring at that time. Maybe some

plaques and tangles are beginning to develop. There's some cognitive issues. What we call brain fog can develop. Memory issues. Word finding difficulty. I can't remember why I went into the room for that reason. Or the reason I went into that. room. I can't remember that person's name. What is that thing that looks like a long, yellow thing? Oh, yeah, that's a banana. Things like that. And a loss of confidence can occur also during the brain fog time period, too, because people are like, oh, my gosh, I'm losing my mind. And that's when estrogen levels are beginning to fluctuate. And energy requirements of the brain are changing. Plaques and tangles maybe laying down. Some vascular changes in the brain may occur

also such that the brain doesn't get the same amount of blood, actually blood flow changes to the brain occur during this time period. And then you look at cardiombatabolic changes, right? Insulin resistance now is really beginning to develop because visceral fat is being deposited at this time. And we can unpack those one by one. But then also bone health changes may be beginning to occur. Sarcopenia occurs. Loss of muscle begins to occur in these late reproductive years into the early perimenopausal transition. sleep disruption is another big one. Women all of a sudden can't sleep. They're waking up between 2 o'clock and 3 o'clock in the morning.

And this is also some signals that there are some hormonal changes which are occurring. And then, of course, there's the mood issues. There's irritability, lability to mood. And then I always look back to this one where I'm going to circle back around loss of self-confidence. It's kind of like a little more antisocial behavior. Like, I don't want to go out. I don't want to do the same thing.

I don't feel good about myself. I don't feel like myself. That's like a very common description I get a lot is that I just don't feel like the same person anymore. I don't feel like I don't feel like doing the same things anymore. I don't have. And I call that joy to be. They don't, people don't have necessarily the same joy to be. I personally, how I got involved in all this originally is at the age of 43.

I was actually running a hugely busy surgical practice. And all of a sudden I walked into the room. And I was a very confident surgeon always. And I walked into the room. I was like, I have to go do this operation now. And, you know, nobody wants a hand. ringing surgeon, right? So I was like, I have to fix this really fast.

And I had gone into the literature. So this is like late reproductive years, maybe early perimenopausal transition. And I'd gone into the literature at the time. And there was nothing in the literature about mood changes during late reproductive years or early pari menopause or hormonal fluctuations. And indeed, there was even a statement that came out from one of the major societies saying mood is not related to hormonal changes right at that time. And this was 20 years ago.

And it was my mother who was like, Oh, you know, you always, and my mom wasn't in the medical business. She was an energy company executive, like she was as far away from medicine as you could get. And she's like, you know, you're acting like you did when you kind of had that PMS that you had a few, you know, a number of years ago. She goes, why did you just try some estrogen? I tried estrogen. It made me feel so much better. So I put an estrogen patch on at the advice of my mother who was in the energy industry, right?

So that shows you. I mean, the irony of this, yeah, is insane. Yeah, and like, you know, I have, I trained at every best institution. I've got every degree. And it was like, I was going into the literature. And it was my mother who said to me, like, do this. It's sort of like the generations of grandmothers who are going to tell you the truth. This gap between, you know, the scientific literature and, you know, what the traditional medical practitioner is going to tell you versus the real world experience of women who are like, let me tell you how it is.

Right. Which creates this strange tension and confusion. Like so many women are like blindsided by this, but what you just described is like, you know, a transitionary period that could span two decades or, you know, at least 15 years of, you know, enduring, you know, going from one thing to the next where all of these, you know, symptoms are starting to occur at creating this confused state among millions and millions of women unnecessarily that leaves them feeling bad and about themselves and powerless and, you know, all the like. Well, this is where this conversation is disconnected, right? So here I am the big academic, or I was just coming off of being the big academic position, right, at the top cancer center in the nation, not understanding this. Princeton, you know, Columbia, you got your PhD at Cornell. Like, you're a baller in this world. This should be like common knowledge, right? It was like my mom, right? But this is the disconnect that we have in women's health, right? Because at some points,

And I'm sure somebody's going to get, I'm going to get in trouble with this. Like, you can get some better information sometimes on Instagram. Now, you can get some bad information on Instagram, but you can get some good information on Instagram. And that's, like, not good. Because we have, we should have a conversation between the academicians and the people who are actually doing the work listening to the narratives. Because the people who are, you know, kind of on the street like myself now or in the past, you know, listen to these narratives over and over and over. And medicine doesn't advance unless you listen to your patients, right? If you're not listening to your patients that you're not learning and you're not curious.

So these narratives are occurring over and over, but you need to have the people who are the policymakers and getting the education out there to take in those narratives also and to process that information delivered into education. And we have many physicians that we need to educate, or health care providers that we need to educate on women's health because these narratives are out there and we need to listen to them. And, but the concept of I don't feel like myself, I don't feel, I'm not the same person that I was, my energy level is in the same. You know, many times you get, oh, you're just getting older, you know. And no, you're actually having real hormonal fluctuations and changes that we can actually help you with so that you do feel back to yourself and that you do feel better. But we need everybody to be in the same room listening and conversing. Yeah. Well, I get moody and I have brain fog and, you know, it's harder to lose weight and sarcopenia and all that kind of stuff. Like, I wish I could be, well, this is why.

I don't have that convenient thing that I can point to. Obviously, there's hormonal changes in men as well. Yeah. It's qualitatively different. So, yeah. So men taper down, right? Their hormones taper down. And women kind of, like, we taper down and then we fall off a cliff.

But interestingly, so at Atria, we started some gender-specific medicine, right? We have that, and I was involved. I'm involved in that and having conversations about that. And, you know, as much as we don't know about women's hormonal health is about as much as we don't know about men's hormonal health also. There's not a lot of data about men's hormonal health, and it probably does have impact on brain health and that type of thing, and that's a whole other area that needs to be looked at.

So I think it just shows us that we have really neglected the impact of what we've called in the past, and it's a misnomer, sex hormones, right? Testosterone, estrogen, progesterone, they're really not sex hormones. They impact the entire body. So I think by giving them that name, we kind of pigeonholed them into reproduction and that type of thing. And we need to look at their impact in a larger manner on the rest of the body. So back to women, when someone comes to you and says, these are my symptoms and they say all the things that you just shared, I mean, what is it that you want the woman out there who is

confused and suffering and in the midst of this transition to know? That there are answers. There are definitely answers. The answers are not always straightforward, right? It's not take a pill. It's a lot of lifestyle interoperable. also in terms of nutrition, exercise, stress management. But there are answers. Like, you don't have to feel like this. And then the real question is, well, then how do you get those answers? And this is the big space, right, that we need to develop in women's health, how we get that

education out there to not only to clinicians and practicing physicians, but also to women themselves. So there are, this is where I actually start to say. okay, there's some really great online platforms for women now. Some of the online telemed is really great now. And that's actually providing a great resource because, you know, if you're in the Midwest where I'm from, right, you're not going to necessarily find a women's health expert. If you're in Manhattan, you're not necessarily going to find a women's health expert. There's not that many of us actually there that go beyond reproduction. But there are companies

that are out there that have a lot of access to them that actually that women can look at also. So I think that that's a good start. I think the first starting point, though, is that you don't have to feel like this. Like, it's not normal to feel crappy, right? If there's something that has changed in your how you feel, that's indicative that there's something changing in your body, and you need to get an answer to that. And that answer may be with your local GP if they're a really great doctor, but it may actually be going to one of these online telehealth platforms, which have been a great benefit for women.

And actually, they'll even do some alliances with some doctors and that type of thing so that doctors can actually refer into these platforms now. I want to get into the interventions, both medical and lifestyle. Before we do that, though, I think it's probably worthy to spend a few minutes talking about misdiagnosis. I would imagine, you know, if somebody's like, well, I have brain fog or, you know, I can't lose what, like, how do you know whether this is related to this transitionary period of life or is something else altogether? that's driving that. Right. So you actually, you always have to do, we call it a differential diagnosis, right? So it's like, here's what it could be. Here's like the three things that are five things that could be. And here's the top on my list, that type of thing. You always have to do a complete workout. Like if you're fatigued and you're gaining weight, you may have a, you may have a thyroid

issue, right? If you have abdominal bloating, boy, you want to make sure that nothing's going on in terms of cancer, right? And this is actually really important because we're actually catapulting into this a little bit that not everything is hormonal, not everything is menopause and perimenopause. or late reproductive years, not all of its hormones. So you have to rule out and you have to make sure that we don't miss those things that could account for it also. So this is where you do need your internist. This is where you do need your GP.

This is where you need your gynecologist to say, okay, here's the things that it could be and let me rule those out because not everything is perimenopause or menopause. In terms of interventions, the number one question that women have is, should I go on hormone therapy or not? This is a much debated topic. I've had Lisa Mascone on here talking, extensively about this as well as others. So what say you, Dr. Pointe?

So I'm a supporter. I'm a huge supporter. So let's substantiate that. Explain what HRT is and your perspective on it. Okay. So HRT, traditionally what we call it HRT, I think we now, we're moving into calling it more menopausal hormone support, right? We're taking it away from that replacement therapy because we're really supporting before you fall off a cliff.

We want to support you, basically. So what HRT has traditionally been thought of is at menopause, right, that you start on the hormones that we lose, estrogen and progesterone, not progesterone for everybody, progesterone if you still have a uterus. That is our older preparations, and we talk about this so much, and so I'm going to briefly talk about it. Our older preparations, our oral preparations, Permanent and Provera that were studied. and the Women's Health Initiative study that made this so controversial. When I started, I always say it's always good to have an old dog doctor because I've seen it all come full circle, right? When I first started, when we took out ovaries, for example, for malignancies, as you were leaving the recovery room, here's your prescription for Prem Pro, right? It's going to prevent cardiac disease.

So we gave you this prescription to prevent cardiac disease like everybody got hormone support. And then when the Women's Health Initiative study came out, looking at did PrimPro actually, or, these two medications protect against cardiac disease. The study showed that not only did it not protect against cardiac disease, it actually increased your risk of breast cancer. But as we're aware, the study population had a number of older women who are many years post-menopause, which doesn't apply to our newer menopausal patients, and also uses two drugs that most people don't use anymore.

And the first one is called Premarin. It's a conjugated equine estrogen preparation. It's oral. It contains mainly estrone, which is an inflammatory estrogen, and this goes back to inflammation. Inflammation is bad, but estrone can cause inflammation in the body, so not good. And it's also an oral preparation. So oral estrogen actually can increase inflammatory markers, again, back to inflammation, C-reactive protein. It can also cause blood clots, right?

You have a two-fold elevated risk of developing blood clots on oral estrogen. In the interim, while the Women's Health Initiative study was being done, we actually developed and we began using what we called transdermal. preparations. So preparations of estrogen that go across the skin. So the delivery method changed to a safer preparation and also to a different type of estrogen preparation, just simply estradiol, not this inflammatory estrogen estrone. So we modernized the type of hormone and we modernized the delivery. We also modernized the progestin component or the progestogen component of HRT. So HRT usually consists or MHT usually consists of an estrogen and a progestogen. Progestogens can either be synthetic.

Those are called progestinns, and those are a little bit more old-fashioned, or can be natural progesterone. So after and during the Women's Health Initiative study, natural progesterone came onto the the market. It was FDA approved around the time that the Women's Health Initiative study was being done. So progesterone is not associated with an elevated risk of developing breast cancer. Synthetic progestinns, which are in IUDs or

in birth control pills or old-fashioned older hormone support, actually are linked to an elevated risk of breast cancer. So not only now our preparations that we use for menopausal hormone support are different in that they are estradiol, which is probably safer than estrone and or conjugated equine estrogens. And also the progestogen is a natural one called progesterone, right, safer for the breast. And also, also, the progestogen is a natural one called progesterone, right, safer for the breast. And also the delivery system is totally different now. So we have transgenital delivery system, which is safer, doesn't cause blood clots the same way. It's not associated with inflammation.

Oral, estradial, elevate your C-reactive protein, elevate your inflammation. Transdermal estrogen, a patch or a cream or a gel, doesn't. So these are two very different things. So it's like saying if I have a statin or a blood pressure drug, right, that this statin is bad. So I'm going to say all statins are bad. or I have this blood pressure drug that's bad. All blood pressure drugs are bad. We don't do that, but we did that with hormones for women.

It makes no sense. We said, this preparation is linked to an increased risk of developing breast cancer, and it doesn't protect everybody against cardiac disease. Now, it probably is protective when you start earlier in a menopausal transition. We can get in that in a moment. But we threw out everything related to hormones. It said, all hormones are bad. And then, again, this is where women's health suffers.

It's like, why would you do that? Like, these are two different drugs, different delivery systems. We wouldn't do that with cardiac disease or lipids, but we do it with women's health that makes no sense. So our neuro preparations are very safe, right? And they also protect our physiology. We know that, and there's a number of meta-analysis that have shown that actually early institution of estrogen actually is cardioprotective, is brain health protective, is metabolically protective, is associated with lower levels of insulin resistance, is protective with bone health also. And we also know that symptomatically, sleep is impacted, mood is impacted, and basal motor symptoms are impacted by supporting with estrogen. So newer preparations are safer.

Newer preparations are going to help you to feel better. Maintaining muscle mass is another one, right? Easier to maintain muscle mass on hormones than not on hormones. So they're going to help your body composition, lower visceral fat. And so you're going to have better physiology, and you're going to feel better also. So what we're moving into, and I think kind of the next phase of this for women's health, is that right now these medications are FDA approved to treat symptoms, right, to treat basal motor symptoms, to treat vaginal dryness, vaginal atrophy, to protect against osteoporosis

and somebody who may be at elevated risk and such. But we need to begin to think about these drugs, I think, a little, are these preparations, I don't call them drugs because they're hormone support, but these preparations a little bit more progressively, should we institute them earlier? We shouldn't wait for symptoms because once symptoms develop, right, already people have put on between an average of five or 10 pounds potentially. But even if you haven't put on weight, your body composition has changed. You have more visceral fat. So by the time, and cholesterol is probably elevated by the time you're having symptoms, brain health is probably changed by the time you're having symptoms.

We need those studies to be done. But we do have Lisa McCosconi studies that do, show that brain health does change in the brain, their brain energetic changes in the peribidipausal transition. But I think we need to start thinking about these more in upfronting them in terms of protecting physiology and not just treating symptomatology. Who is not a candidate for this? I mean, as an oncologist, you know, there is, it's like if you are genetically predisposed to cancer or you're in remission from a cancer, does that mean that you have to opt out of this? What should somebody know who is concerned about this? Who are the people that should focus more on lifestyle interventions?

Let's talk about genetics first. So I'm a walking textbook of GYN oncology. I've had HPB-related cancer. I'm Brocka 1-1-positive. I found out actually this year that's Brocka 1-positive. And that's the genetic predisposition. So 90% chance of getting breast cancer. So I'm continuing on my hormone support right now.

I'm going to do my preventative surgery, but until then I'm still going to continue you on my hormone support because estrogen doesn't cause breast cancer. Estrogen can cause a breast cancer there to grow, but to our knowledge to date, it's not a promoter of breast cancer. So it's like fertilizer, right? You can have all the dirt with no seeds on it, right? And you can throw all the fertilizer on the world and nothing's going to grow, right? But if you have dirt with seeds, it'll make it grow.

So I think of estrogen more as like a fertilizer in terms of making cancers grow that are already present, that may change in the future with additional studies. But right now, laboratory evidence does not suggest that estrogen is a promoter of cancer. So if you have a genetic predisposition to cancer, whether it's a Broca mutation, check two mutation, polygenic risk score, which may be elevated, it's not a contraindication to using hormone support. If you've had a history of breast cancer, right, currently the current guidelines are no estrogen. Because what happens with breast cancer is by the time we find a breast cancer, we consider it systemic because it can come back later,

20 years, 30 years later, right? So what you don't want estrogen to do is not that we're worried about causing another cancer. It's we're worried about waking up another cell that's in your body that you may have been treated and cured, right? But again, this is the sneaky one that can come back later in life, and so we don't want to wake up those cells, right?

So that's a whole area of conversation for the future in terms of hormone support after breast cancer diagnosis. Because remember, we allow women to get pregnant after breast cancer diagnosis, but we don't allow them to use hormone support. Now, one is reproduction, and the other is maybe quality of life

and some physiology protection that we can do through lifestyle also. But there are women who desperately suffer with hot flashes and mood issues and bad issues symptomatically after breast cancer diagnosis, and those are women that we need to converse with. Can we get them a serm on board at the same time?

is estrogen to help them symptomatically. So that's more progressive thinking, and that people are thinking about that. So that if you've had what we call an estrogen-dependent malignancy, we usually don't recommend hormone support. Early uterine cancer, you can still use estrogen after that. Late-stage uterine cancer, no. If you've had a previous stroke, very difficult to prescribe estrogen after a previous stroke, although our newer preparations of transdermal estrogens don't increase stroke risk when

kept at a reasonable level. They may be associated with an elevated stroke risk with their little bit of a higher level. Prior heart attack, again, conversation with the cardiologist because estrogen can destabilize plaque, potentially. There is transdermal estrogen probably doesn't destabilize plaque the same way that oral estrogen does, although there's a pathway in the plaque formation process and destabilization process that transdermal estrogen can hit. So these are great times to have. So if you have a high calcium score or something like that. So that's, we have to speak with the cardiologist, right?

That's where, so I have some people with elevated calcium scores that we do have on hormone support for specific reasons. And this is where the conversation with your specialist is really, really, really important. So it's not an absolute contraindication. It's a relative contraindication that needs to be conversed with the treating cardiologist also. Those are the big contraindications. And, of course, if you have abnormal vaginal bleeding and you don't know where it's coming from, that needs to be evaluated beforehand. But again, these conversations are changing and becoming a little bit more progressive as we develop maybe selective estrogen receptor modulators to block the estrogen on cancer cells and that type of thing. Basidoxapine is a good example of this.

So that this is a serum that will actually, that's part of duavi, which is an oral estrogen, is primarin plus a basidoxapine, which is associated with a lower risk of developing breast cancer. Not, you know, so interesting. So that baz is blocking the estrogen receptor in those cells. So again, these are conversations that I think that I'm really looking forward to in the future and data in the future, looking forward to this. In terms of phasing into this, I'm thinking of the 35-year-old woman who maybe is asymptomatic, but, you know, perimenopause is either on the horizon or in its early stages. This person comes to your office and, you know, they want to get ahead of this. Yeah. So is HRT something you would advise or counsel that person to get on in advance of becoming symptomatic?

How does that work? So for women who are asymptomatic, we begin to look at family history then also. And I'm specifically at family history of dementia. We have a very large brain health effort at the institution where I'm at. And estrogen most likely is protective against developing dementia. So if you have somebody who has a very high risk of developing dementia, maybe they have two APO-E4 alleles. These are two genes that will, a gene that will increase your risk of dementia and a big family history of dementia. We will follow that person really closely and look at their hormone levels really, really closely, actually, and begin to talk about with them estrogen support before developing symptoms.

That's a very highly specific population. But I would imagine that as we learn more about this, remember, we don't know very much about this. We always go back to one study of two drugs that we don't use anymore. So this is an area that we're learning more and more about. So there are definitely some very highly specific populations and asymptomatic individuals that will begin to say, oh, we need to talk to you about not letting your hormone levels fluctuate. We don't want you to lay down any plaques and tangles. We don't want the energy metabolism of your brain to change.

We don't want to give it a chance to change. But this, again, is very highly specialized, highly specific. But so in women who want to get ahead of it, I always say, listen to your body, listen to the narrative of your body, right? Do you feel well? Do you have your same energy? Is your muscle mass the same? You know, how's your mood? You know, looking at the things that we just spoke about, right?

One thing that we're trying desperately to work on and develop is like, how do you measure this transition, right? We have these crude measurements that you get hormone levels. drawn is everybody's like, oh, everything's okay. Your hormone levels are okay. Well, they're really not. Like, your progesterone may be going down a little bit. Your estrogen may be fluctuating your ovarian reserve is falling off. How do you combine that? How do you combine maybe hormonal data, which is done on a specific day of the month? Just a snapshot. Yeah. Like, maybe we could do like a day three FSAH, right? This is just an example. A day three, FSAH is the hormone that drives the ovary. So as your FSAH goes higher,

your ovarian function is lower, right? So maybe we could, can get like a specific snapshot of your FSA, listen to your narrative, get some wearable data with your, you know, whatever wearable you're wearing, right? And then begin to combine it with like maybe other biomarkers of inflammation. As your estrogen level drops, your inflammation increases, actually. So there's some very specific inflammatory markers that increases estrogen levels drop. So we need to begin to come and put together algorithms of how we can measure where women are in these transitions, right? And then that would provide the, practitioner with a more binary approach, like, yes, this is going a little bit off for you,

and we can begin to provide some hormone support for you so that you don't have to suffer, right? But until we get those measurements, that's very hard, it's more of a gestalt of like, okay, this is the narrative, this is what I'm hearing, this is how I'm putting together. This is where AI can be really, really, really helpful, I think, in terms of, you know, going through these very intense narratives and maybe some biomarkers and hormone levels on specific days and putting the picture together to say, okay, now we want to start. Are we in a position now to say outside of these very specific populations, everybody should start when these changes occur? I think that's a very personal decision. I definitely have, I think are women in their 30s and 40s

now, are like, I just want to check my hormonal health. I want to find out how my hormones are doing. I think a lot of that is social media too, right? I love it. Those are my favorite consultations because that means I have to do a really deep dive into their health. And for women who may have some subtle symptoms. Probably everybody has some symptoms, actually. We just don't recognize them as symptoms. So, but for women who have changes that are bothersome to her, let's say, I'll begin to talk to them about hormone support early. And that's a really, that, that is progressive, but we go over the risk and benefits. We talk about, you know, what the standard recommendations are, what the standard guidelines are. But these are estrogen levels and estrogen dosing levels that are much

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So what do we know about the relationship between these hormonal changes that are taking place during paramedopause? and menopause and the impact or the incidence of risk that that poses to succumbing to one of these degenerative diseases. So women as they transition through pariaminopause will definitely have changes and potentially changes that goes back to the brain fobbing cognition, right, or perceived changes. So, you know, memory issues, word-binding difficulty, things such as this, right? And those do correlate as a number of physicians have shown, Dr. Mosconi in particular, that they do correlate with energy changes, how the mitochondria works in the brain. There is some possibly what we call insulin resistance in the brain, right? The mitochondria of the cells, or the powerhouses

of the cells don't use glucose the same way in the brain when there's lower estrogen levels or estrogen levels are actually fluctuating. There's brain volume changes. There's actually changes in the actual structure of the brain actually as estrogen levels are fluctuating. Blood flow to the brain can change also. And so there's a number of, like well-defined physiologic changes which can occur. What we need to show, though, is that if we provide estrogen, does that correct some of these changes? And there's definitely data to support that.

We do know, and there's also epidemiologic data and some observational studies that show that more exposure to estrogen over a woman's lifetime actually leads to lower risk of developing dementia. We do have studies in large meta-analysis that show. that if you institute estrogen between one and three years within the period within the menopausal transition and this is late I think I mean this is we're talking one to three years after you stop a period right that there's a 32% risk lower risk of developing dementia or Alzheimer's disease so that data does

exist it gets a little it gets a little skewed or a little dicey when you begin to look at some of the women's health initiative study data but this again is with an oral estrogen which is inflammatory and neuroemorty neuroinflammation actually contributes to dementia so that we have to look at transdermal preparations. And we have to really, and I'm a little crazy about this stuff. So I have like a giant spreadsheet of, I did a PubMed search. And I just put in estrogen, clinical trials, estrogen, women's brain health and got 300 pages on PubMed. And that's like 10 studies a page, right?

So that's like a lot of information on PubMed that we have. And this again goes back to curiosity and reading across your specialty. So I'm a gynecologist, cancer surgeon, but I read the neurologic literature, right? Because that's the only way I'm going to understand the impact that estrogen has on the neurologic literature. Now, if you put in estrogen, if you put in menopause in brain health, you don't get nearly as many hits, right, as you get with estrogen. So you have to know what to search on.

But what I try to do, and what I'm trying to do, because I still have this project going on, is I'm reading every study and I'm looking at how many people got transdermal estrogen and how many people got oral estrogen. I want to correlate and find out of those studies that looked at transdermal. estrogen, what were the brain changes that were associated with transdermal estrogen? And some of these are just what we call functional MRI studies, meaning that they just gave women estrogen and just did MRIs of the brain to see what happened. But can we correlate, is there a difference between oral estrogen and transdermal estrogen

when we begin to tease out these studies a little bit? There has to be, given the inflammatory markers with oral estrogen. Yeah. And there's some data that I'm looking forward to being published that I know a little bit about that shows that when you give women estrogen, that actually what we call brain biomarkers, so the measurement in the blood of what's going on in the brain are actually improved when you use estrogen.

And that data will be published in the near future. So those are what we call surrogate endpoints, right? So are we ever going to have like a large phase three randomized controlled trial that shows transdermal estrogen prevents dementia? Probably not, because what woman at this time is going to enter into a randomized control trial? I'm just like, I can't think of any of them. Any of us, any of us that would. So we're going to have to look at what we call these surrogate markers.

And those surrogate markers are going to be things like functional MRI. They're going to be things like brain biomarkers. Now, the interesting question is if you have an older individual who didn't have estrogen because they were part of this generation of women who were not offered estrogen and told that estrogen is dangerous because of the Women's Health Initiative Study, now they're coming to us saying, well, should I be on estrogen? And we know that, and I call that late start estrogen, so after 60, because really the kind of the conversation now is before the age of 60 or within 10 years of menopause, estrogen is considered safe. But there is some data that shows that what we call later start estrogen actually may increase plaques and tangles in the brain and may actually be not good for your brain health.

But again, that data is based on oral estrogen. It's not based on transdermal estrogen. And if you look at some of those women in brain biomarkers, some of the data suggest. and again, not published data, and I look forward to this being published, suggests that the brain biomarkers get better, even with transdermal estrogen when you're older starting on it. So I'm anxiously awaiting that data. But these are the big questions,

because we do have a generation of women who did not have estrogen and who are now questioning whether it's good for their brain to be on estrogen. Yeah, I mean, I just think that, you know, what you just shared is so vitally important because I know that, you know, women are confused about this. they ask their friends. There's all kinds of conflicting information out there. And so if there's one thing to take away from this, if you're between the ages of, you know, I don't know, 35 and 60,

like go to a women's health specialist and open up this conversation. And, you know, maybe stop taking advice from your friends or try to get to, you know, the truth of what can be helpful to you. Yeah. And I think this is where we really need to define this specialty. And I love the fact that you took 35 to 60 because that's exactly kind of the age range that, I've defined in terms of that we need to really put together an algorithm for practitioners to

practice by in terms of conversation with their patients. And an algorithm sounds like it maybe trivializes it, but it gives them a starting point. Like, here's a starting point. And we need to really define who's going to do this and get that information out, out to people, actually. And that, and it's smack down between 35 and 60. Before we move into lifestyle interventions, is there any other medical intervention other than HRT that is on the table here or worthy of discussion, or is it really just HRT is the thing? Well, in terms of management of symptoms, right? I think that for women who have a history of breast cancer, especially, or can't take estrogen,

maybe they had a stroke or something, who are having ongoing basimotor symptoms, that there's a new class of drugs that's out, that's a CNS acting class of drugs that really helps with hot flashes. Vioza is the name of the first one. Bear has a new drug that is coming out, actually. And so there are options available that if you've had a history of an estrogen-dependent malignancy and you're suffering, there are options available for you

in terms of speaking to people about some hormone support necessarily. I think it's also important. And I always assume that everybody knows this, but it is not necessarily common knowledge that if you're having vaginal dryness, right? So we talked about libido and some of the other symptoms, but painful sex is a big symptom, right, as estrogen levels are falling,

and what we call dysperonia, and vaginal estrogens have been kind of equated and associated with systemic estrogens, right? And that's why vaginal estrogens had this black box warning on them that was recently taken off. And vaginal estrogens are extremely safe. Even if you've had a stroke,

we know that low-dose vaginal estrogens are safe. for you so that you don't have to suffer from painful intercourse or vaginal dryness that can actually be associated with recurrent urinary tract infections. So local vaginal estrogen is very different than systemic estrogen, and the contraindications to systemic estrogen don't apply to local vaginal estrogen. So, again, it's a little bit of a nuanced conversation in some ways, but to realize that always have that conversation.

So talk with about hormone support and other pharmacologic interventions. Also, it's interesting, too, for some women who are going through perimenopause, some women just do better with a birth control pill, like a low-dose birth control pill. I was never a big advocate of that until I came to my current position at Atria and I was working with an endocrinologist. I was always much more and more natural, right? I was everything, I like to do everything as natural as possible. And I think birth control pills is highly synthetic and highly manipulative. But some women just do much better with a birth control pill during perimenopausal transition.

So even if you have a more natural approach to your health, you still may get some benefit from a more synthetic approach also. So don't take that off the table. What is your advice for the woman who's trying to find a really good women's health specialist in their area? Are there resources or, you know, what are the parameters that you can? There's a group called the Menopause Society, actually. And again, I don't like to use the word menopause or perimenopause because it means that you, you know what's already going on. You know it's parimenopause, right?

There are so many women who are having hormonal symptoms who don't, who before the years of perimenopause, right? Or before the years of menopause, so to go into a menopause group or a perimenopause group, you have to know that's what it is, right? So I don't like those words. But there is, and that goes, menopause is kind of interesting. I just want to segue a little bit. Menopause was coined in, the term was coined in 1821.

So we are still using antiquated terms from like, it's like women's health is so. It's been thought of as this on-off switch, essentially. Yeah, no, yeah. It's like, yeah. So, but there is the menopause society, which does have a great resource of menopause practitioners, actually. So that can give you a list of people who may have specialized expertise in women's health to go to. So that's one group to go to. And then I say go back to these, like on these online groups are actually, they're actually really good.

They're actually run by some of my friends, actually. And they're actually really, really good. I was like, I like longitudinal care. I like having that patient physician relationship. So when these first came out, I was like, oh, my gosh, another telehealth platform. You know, you're not going to have that great longitudinal patient physician relationship. But they have been, I've been proved wrong in that. They're really great, actually, for some women.

Do you know Robin Berzin, personally health? Yeah, I mean, I think she's doing a fantastic job with what she's doing. What are the questions that a woman should be prepared to ask, you know, when they go in for one of these appointments to make sure that they're, you know, with the right person? I think do you prescribe hormone support is a big one, right? That's like a, it doesn't mean that you need hormone support or that you're not looking for it. But do you prescribe hormone support? Because if you have a clinician who says, I never prescribe hormone support is dangerous, then you know that they're not up to date. And some of this becomes a little emotional for people too.

It's kind of weird. Again, like women's health has some oddities to it because some people just hang on to these beliefs that hormone support is bad. So, but I think that that's a really good question in terms of because if you have somebody who's says, or you can say, what are your views on hormone support or ages at institution of hormone support, right? Those will give you insight into how they practice, basically. Those are two really important questions because they just get right to the heart of the matter. And it means that if they say that they don't provide hormone support or they don't have experience

in it, you can say, what is your experience in hormone support? It means that they don't have experience in women's health. Because women's health is, so much of it is seen through this hormonal lens, right? if we need to look at women's physiology through this hormonal lens so that if you're not prescribing or you're not, you don't have expertise in it, then you're not thinking about women's health across that hormonal lens. You can go there, get your blood pressure checked, maybe your body comp done, that type of thing. But to get overall kind of holistic wellness, you're probably not going to get it in a situation like that. And if somebody's going to do a blood panel or, you know, have lab work done, what are the markers that are most important? I think in terms of hormonal transition markers, right, it's going to be like a day three FSAH, right? And people won't, people won't draw that. I mean, that's just not done.

People say, don't draw your hormone levels, yeah, because, and they might not even draw it if you ask for it. Because I say, we don't check your, we don't, we don't check hormone levels because they don't mean so much. And I actually had a conversation with a very smart doctor the other day. He goes, it says it's normal. And I was like, no, it's not normal. It's normal because his flagging is normal, but it's not normal. But in terms of important panels, and if you're on hormone support, Actually, I'm a big advocate of checking hormone levels because you don't want to just be on a level that's not going to provide you physiologic protection.

But again, the basic things for women, too, are cholesterol, right? Cholesterol panels, APOB, LP-L-P-L-A, looking at more progressive looks at cholesterol because the estrogen can impact actually subtly, but can impact the level of L-P-L-A and have, if L-P-L-A is a very atherogenic lipid, meaning that it's one that really can deposit in your coronaries and cause plaque, and estrogen can have some impact on that. Those late reproductive years, early perimenopausal transition is when cholesterol is beginning to change. So women really need to, I think the current guidelines are check your cholesterol every two years or something like that. But it really should be every six months to every year.

Blood pressure is super important. Actually, blood pressure starts to go up, actually, as women go through hormonal fluctuations. Hemoglobin A1C or any type of measurement of your insulin resistance, is super important. So either Homa IR to look at your insulin and how it's being utilized, fasting insulin, hemoglobin A1C is a very basic one that just shows you how your glucose control

has been over the past three months. So looking at your lipid, your cardiometabolic status, really, really important. Blood pressure is one we kind of forget about. You know, definitely, we forget about it in the conversation because we know it's important, but I think we sometimes don't emphasize

how important it is, right? So making sure that blood pressure is under good control. Waste to hip, circumference, super easy, right? You just need a tape measure to measure your waist and to measure your hips. And it should be less than 0.85 is where it should be in terms of, I have to go, is it lower or greater.

But it should be less than 0.85 actually to indicate kind of metabolically fit, right? Because that's a very crude way for us to show us your body composition, right? So the larger your waist, the more visceral fat that you have. means that things are changing. And we measure BMI a lot of times in the physician's office or the healthcare provider's office, which is almost a meaningless number because you can be super healthy and have a higher BMI, or you can be of a different race and have a higher BMI. So we need to begin to really look at waist to hip circumference. These are metrics that we need to look at. But when we look at hormone panels, day three is the most valuable, I think. If you have somebody that you really want

to map, like for our patients who maybe are at elevated risk of dementia, we really want to map their hormones will check hormone serum levels over the cycle at specific days of the cycle. Or even you can move into some of this home urine testing, which I love, actually. One is called Dutch testing, actually, which is very validated in terms of looking at estrogen and progester and estrogen metabolites. There are newer tests now that are coming out in terms of home hormone mapping. I think some of them need to be validated and we need to understand how to use them. And I think that's where the interplay between home urine hormone testing,

wearables and what goes on in your physician's office is going to be that triangulation is going to be really, really, really important. So those are things that we look at also. What about bone density testing? Yeah, super important. So it is recommended to start bone density testing at the age of 65, which makes no sense to me, right? That's like after, you've had like, so, it's no sense. I mean, this is where the health care system makes, no sense. So, yes, definitely. Let's start testing when we know it's already, you know, falling off a cliff. Yeah, and I actually, I have a story for, I have a lot of stories.

I have a mom who, my mom, you know, who got me on the hormones actually took every osteoporosis drug and never exercised and had the worst osteoporosis in kifosis. So we need to pick these things up early so that we're not just giving you a drug that we're preventing, that we can provide you with lifestyle intervention. So, you know, definitely Dexa. I like Dexa body comp. You get bone mass, you get your body comp and your bone mass with that. Dexa. But there's a little fear around that though, because if you're going to do that, you're probably going to find something, right? If you're going to do that full body scan, sure. And I know people that get freaked out by that or that, you know, they do find something.

It turns out to be nothing. But, you know, it can be alarming. That's where you need guidance, right? So that's where guidance comes in because you shouldn't be with like a total body MRI or total body scan, right? It shouldn't be just order. This is where longitudinal care, I think, becomes really important, right? If you go to like a clinic and they do all these things for you, but they don't provide you the interpretation of them. They're, they're scary and meaningless, right? So, but, you know, you can look at something and say, oh, that's, that's nothing, but we'll just follow that up in three months, right? And this is or it's something, right? And then we need to intervene and we picked up something early.

This is where interpretation matters and this is where an experienced clinician really, really, really, really matters in terms of helping to you interpret. I mean, that's, that's the job of us as health care providers is to not leave you out there. Oh, we found something. And now, what do we need to do? It's like, we need to guide you through that and give you the reassurance when it's appropriate or get the action when it's appropriate. We're in this weird situation right now where so many people don't even have a primary care physician. If something happens, you go to urgent care or you go to the ER.

But at the same time, we have just insane access to more information than ever, not just on the internet, but through our wearables. So we can amass gigantic amounts of data on what's going on in our body. But without that longitudinal care or that primary care physician or somebody who is interpreting all of this, we're left to our own devices to try to understand what all of these things mean. Yeah, this is why when physicians are afraid of how AI is going to take over my job, I'm like, no, they're going to make more work for you because that's more information for you to help to interpret for your patient. Yeah, I mean, there's a lot of hand wringing around things like CGMs.

And it's like a scale, it's giving you information. I think the fear with, you know, somebody who might be, you know, standing where you are is just that they understand that there needs to be some real interpretation of this because without that, it can drive unhealthy lifestyle choices. Totally. And that's where it used to be Dr. Google, right? Like, I'm going to Dr. Google. I love it with my patient's Google because I get, they actually bring me information sometimes

I didn't know about, right? And I go and I read it. Yeah. So I think I love Dr. Google. and now it's like Dr. AI or Gemini, whatever you get. But I think that we need to really help people and interpret this information. And that's going to give us as physicians just, you know,

a lot more work to do. And it also provides, I think, even more import to the health care provider in terms of, you know, being there to guide you because I always say that if I can't interpret this information better than you can interpret it or from a different lens, It's not even better. Better is a bad word, but from a different angle, from a medical angle,

then all that money that my parents spent on my medical education was totally wasted, right? I mean, there is something to this education that we go through in medicine and that our clinical and lived clinical experience is important for. And we should be there to help people. We should. People really do still need that primary care position or that consulary, you know, type of person to help guide them through this. And I think I love, like you bring up CGMs.

I love CGMs because, they can, you put one on for a couple weeks and you can see, okay, what's, what's working, what's not working, and then take it off, right? And then you've had a lifestyle intervention. It's important, though, not to get so caught up in it, right, and get into those unhealthy, you know, unhealthy patterns. But that's where a really- Or just being neurotic about it. Yeah, right. Yeah, it's totally over-obsessed. I tell people sometimes take off your wearable. Like, if you're obsessing about it too much, just take it off, put it in the drawer for a while. But to have that conversation with somebody say, just take it up,

put it in the drawer, take it off, you know, is really, really important. So I think it's even more important that we have people guiding people through this information, this vast amount of information that we have, which I think is totally exciting. I think it's a huge opportunity for health care providers and physicians. Well, let's talk about these lifestyle interventions. There's two things that I think are great about this. First of all, you know, what's good for the middle-aged women out there who are navigating this period of life, you know, what's good for that is also good for longevity. Like, these are just good things to do for anybody at any time. So you're serving, you know, many goals by doing this. It gives people agency. You know, there's

this idea like, well, this is just what happens. I'm going to have brain fog and I'm going to be moody and I'm going to wake up in the middle of the night and there's just really nothing I can do about it. Yeah. So this is why midlife is so great for women. So I have this very positive outlook on midlife. This is like the beginning of the rest of your life. These are the great years, I think. And this is also where you have to decide, how are you going to age, right? Are you going to age passively? And I always use the example of like an old vintage car, right? So I have this old Mercedes that I'm like rehabbing right now.

And if I leave it out into just to nature, it's just going to fall apart, right, and rust. But if I take care of it, if I drive it down the highway, I get all sorts of honks and winks and all sorts of stuff, right? because it's in great shape, it's functioning well, it goes fast, it has great acceleration, right? So it's really true to the human body, too. If we just age passively and, you know, eat what is fed to us and just like kind of let everything go, you know, we're going to naturally deteriorate, right? Like, you know, nature usually takes over a house, right? Nature always takes over. But this is a time where we can actually really change our actions or make a decision to really, change how we're going to take agency. It's not even to change, but to take agency on how we're going to age. And midlife is the perfect time to do it for women, I think. It's a time where we're post-reproductive years, right, so we're not worried about fertility, children. We can now focus,

and it's not selfish to say focusfully inward, I think, but we can focus on our own health and longevity, right, to accomplish what we want to accomplish in our lives or how we want to live our lives. But that is a conscious decision and it is a decision that I am going to move my body every day. I am going to make time to move my body every day. I am going to make time for sleep. You know, sleep is so important and we think that it's kind of passive. It's just kind of at the end of the day. Oh, I'll go to sleep now. Yeah, it should probably be, I have to schedule my sleep or I'll never sleep, right? So, or I'm going to consciously eat in a thoughtful manner, right? I'm not going to, I'm not going to just eat what is, you know, what's easy to grab, right? So these are conscious

decisions that will help us feel better and help help us with our health span. And I think that, again, we have times in our lives where we have to make decisions. And I think for women in midlife, many women are forced in midlife to make a decision. Because most women don't go through midlife physiologic changes and say, I feel great. Some do. I mean, I definitely have, I definitely encounter patients and I definitely have passions that say, like, I feel great. I never, never impacted me once. But that's the minority. That's probably about 10%, maybe 20% of the people that I've dealt with. And I've had a busy practice and seen thousands and thousands of patients. And the ones that feel great probably don't come to you either, right?

That's true. Well, I get some of them. Yeah, I get some. But probably the ones that feel great, I already have a great lifestyle too, right? They probably already embrace some of these lifestyle changes. I was actually thinking about this the other day. So I, like, again, I have a story for everything, right? So I'm actually sitting in the hospital. I had my prophylactic surgery for my BRCA mutation, right? I had a hysterectomy. I had a high-grade bowel obstruction and was very sick and in the hospital and lost a lot of weight. And for one day was very, like, very out of it, like, acedotic, like very, very, very, very sick. And I kept dreaming during this dream. And it was like, But the dreams were all about it was odd being on a golf course with my father, where I realized that every major life decision was made being on a golf course with my father.

And I made a decision that when I got out of the hospital, it was going to be as healthy as I could be. And since that time, I haven't missed a workout that I'd planned. I haven't. My nutrition is much different. So I think that when we make lifestyle interventions, like decisions to do them are really, really, really, really important. And I think, again, for midlife women, it's a really, it's a pivotal time to make those decisions to approach a lifestyle. So from your perspective, what are the non-negotiable essential pillars of this? Non-negotiable, I think, you know, there's three that are non-negotiable.

And people ask me to kind of order them all the time. And depending on the kind of what I'm thinking about at that time point, I'll prioritize them. But the three non-negotiables, right, are sleep. really, really important, nutrition, really important, and movement. I usually put movement first. I always say it's better to have more movement and less nutrition than more nutrition and less movement, right? So I think movement is probably the top on the list, making sure that you move every day. And we can go into the nuances of that.

Nutrition, of course, eating whole foods, largely plant forward, paying attention to carbohydrate and protein content and being protein heavy for women in terms of paying attention to protein for the first time, probably, in many women's lives. At what age does that emphasis on protein become meaningful? Late reproductive years. We start losing body mass in our late reproductive years. So it starts early, that what we call sarcopenia starts early. So I usually just when people are done with childbearing, because during those childbearing years,

it's hard to really, you're focusing on just kind of making sure everybody's taken care of. right and making sure that your body is either, you know, preparing for pregnancy during pregnancy or recovering from pregnancy. But once you've recovered from pregnancy in those late reproductive years, I think that's the time to really focus on being protein forward and focusing on, you know, I usually recommend one gram of protein. If you need to build muscle, which most women do need to build muscle, some don't, but most do, one gram of protein per pound of ideal body weight. Which is a lot. It's actually a little tricky to meet that. Yeah, we work on, you know, high-protein snacks and, you know, what you can, you know, based on your eating style going through nutrition plans.

But yeah, but that's why I say for most women, we haven't, but we don't focus on protein so much and it's not so easy to get protein in. But if you focus on getting, you know, 30 grams of protein at each sitting of some sort and then, you know, adding in some high-protein snacks, probably can get it in. Stress management also really, these are, you know, you ask me the top pillars and I gave you the movement, sleep and nutrition. Stress management, really important also. That goes back to inflammation, right? That segues into sleep also. And then the one that we don't talk about so much is connectivity, right? You know, being engaged, moving forward, sense of purpose, happiness, mindset.

I put those all together. and super, super important. And I don't think we talk enough yet, and I'm hoping this conversation changes about mindset and what we call happiness in midlife women. I mean, we know that we all have a lot of stressors in midlife. We're going through hormonal fluctuations.

We have physiologic stressors. We have life stressors. But we really need to begin to provide women on the tools to develop the mindset to be able to cope with these stressors and to move forward and to find, and achieve that happiness or that satisfaction with life. And I think that's another big one that we need to talk about also. If you're suffering from a lack of meaning in your life or a sense of not having a purpose,

I mean, I think, you know, it's not uncommon for people at a certain age when they become empty nesters and the kids are gone and they're sort of like, well, what's now? Yeah. And not knowing an answer to that question or not knowing how to plug yourself into life in a way that, you know, you're feeling nourished and purposeful is going to, you know, create downstream health consequences. Totally. And then you put like just the changes in empty nester, relationship changes, then put hormonal fluctuations on that, too, on top of that, right? So depression, anxiety, and women is higher than compared to men. Depression that was maybe

subclinical may come out when hormone fluctuations come out. We talk a lot about depression and anxiety or we talk somewhat about depression anxiety in women in midlife. But again, that sense of purpose, that community, that concept of mindset happiness that that may not be not true depression, right, not clinical depression. We need to talk about the other aspects of women also who may not be clinically depressed or have clinical anxiety but are suffering. We need to talk a little bit more about that, I think, and helping women 100%. And, yeah, because it provides more stress if you don't have.

have a sense of purpose or a meaning or a community. It is very difficult, I think. You probably know that Rivian makes all electric trucks and SUVs, make that the best all electric trucks and SUVs. But did you know that Rivians actually improve over time through software updates? Through regular over-the-air updates, the technology keeps evolving. New features, improved performance, additional safety features. So your vehicle, actually becomes more capable the longer you own it. And knowing RJ, Rivian CEO, I can tell you firsthand that this is a guy who is not into tech for tech's sake.

Every feature is designed for actual real-world situations, like pet comfort, maintaining cabin temperature so your dog stays comfortable if you need to step away briefly, adaptive lighting that responds to the environment, plus warning systems and highway assist that monitor. monitor the road alongside you, making the driving experience safer and more enjoyable. I'm so proud to partner with Rivian. They're just the best, everything you want out of a vehicle, of course, but also because of their ethos, which is making the world a better place, providing what you need to make the most of life's adventures and using technology to do it. So you're prepared for whatever comes next and have everything you need for every adventure you can imagine.

One of the really great things that I've noticed over the past few years is this incredible uptick in education and awareness and interest all around the importance of sleep. So much to say on this subject, but the main thing is that you need to build good sleep on a solid foundation, meaning your mattress is super important, not something to smirk at or dismiss, which is why I sleep on and support mattresses made by birch. All birch mattresses are made from natural, responsibly sourced materials, which means I'm not lying on a bunch of synthetic foams or breathing in, questionable off-gassing. It sleeps cool, it's firm, luxurious without being soft. It's just really thoughtfully designed, beautifully made, and built to last. They're shipped straight to your door, rolled up in a box, and super easy to set up. You get 120-night risk-free trial, and they believe so strongly in their mattress quality. They back it all up with a limited lifetime warrant.

guarantee. So I want all my listeners to enjoy a deep, restful night's sleep with a new mattress from Birch. Go to birchliving.com slash ritual for 20% off site wide. I would imagine that, you know, a typical scenario is a woman comes to your office and they say, just help me not wake up in the middle of the night or, you know, what can I do so that my memory isn't so shaky and like, how can I just lose this weight? You know, like, right? Like, it's like, the weight thing. It's like, That's got, there must be, you know, that's what they lead with, right? So, yes. This is what we're all thinking about and worried about.

Yeah. Does the advice change? Like, is there any special sauce here, you know, that you can give that person who's like, well, try this or that? Yeah. So if we have somebody, if I have somebody who, let's just talk about weight, right, first, before sleep. Because sometimes when you fix insulin resistance, you fix sleep, too.

So if you have, if I have somebody who, who is not optimized, right? Many of the people come to mirror are super optimized, right? They're already, you know, nutrition. You know, they're already focusing on protein. I think, you know, everybody has a different carb tolerance, right?

We all have different genetic backgrounds, right? So this is another thing about nutrition. I think it's really interesting. We can say there's not one secret way to eat for everybody, right? We all have different, you know, some of us are from sub-Saharan Africa. Some are from, you know, areas of the Arctic, right? I mean, so we all have different genes.

We're all going to process nutrients. a little bit differently. So what works for one person doesn't work for another person. But what does work, I think, is focus on protein and then slide your carbs up or down and keep good fats, right? So some people have a higher carbohydrate tolerance than other people, right? So, you know, in your macros, right, when you're looking at 30 to 40 percent protein or usually 40 percent protein, that 30 percent carbs might be too high for somebody or might

be too low for somebody. So beginning to look at what works for you. Like, where are you with your fighting weight? do you want to be with your weight? Where do you want to be with your body composition? And then look at what works for you for your nutrition. Movement can be a little bit less individualized, right, than nutrition. I think nutrition's a little bit more individualized. So for movement, I recommend lots of strength training. This is where, again, women become very deficient. You know, women do a lot of aerobic activity. We used to go to the gym to lose weight and to do aerobics, right? And we really

need to go to the gym to lift to lift weights. And we need to go to the gym. I think we need to lift, to lift heavy, lift progressively, lift safely. But we need to lift like three or four days a week, actually, or at least three days a week. And, you know, the recommendations now kind of are like, well, strength training two or three days a week. It probably should be a little bit more if you want to build muscle. Because when you're going through hormonal fluctuations, it's harder to build muscle. I'm actually going back to get my certified personal trainer certificate so I can learn more about just training, actually, and then go.

You're not busy enough. You don't have enough degrees. But as dog, if you think about it, physicians were like, we're just like, oh, go eat better or just go move or go, but people need more than that. They need a program. They need how do I move? And we as physicians, I think, are we need to understand what we're recommending, right? So, so in terms of like movement, so, you know, again, 150 minutes of aerobic exercise, do what you love to do. Maybe that's cycling, maybe that's running, maybe that's walking, maybe that's, you know, being on a treadmill, walking outside. I like to walk

Manhattan. And then the strings training thing is super important to build muscle, not lightweights, but lifting progressively heavier weights is important. And then in terms of sleep, right, so you need to sleep to lose weight, right, or to change your body comp. Because if you have bad sleep, your cortisol levels are higher. Your insulin resistance is higher when you have higher cortisol levels. If you are doing that, if you are doing all the right things, right, which a lot of the people that I see come to me doing all the right things is then what do I do? None of this works anymore because this is a common story. Like, I'm doing everything right, but none of this works anymore.

This is where the GLP ones, actually, I think, are super, super valuable. This is where pharmacology can come in to be super, super helpful. Because this is a problem of insulin resistance. Because as women, as we lose estrogen, we put on visceral fat. That's the fat that surrounds our organs, our abdominal organs and such, even our heart. And as we have visceral fat, that increases insulin resistance, right? So the GLP ones break this insulin resistance. They also break food noise, which I find is really interesting.

I think a lot of midlife women have a lot of food noise. And the GLP ones thinking about food all the time. What am I eating? What am I eating? What am I eating? What am I eating? When is my next meal? Just like kind of thinking about in the background about food.

And there is something called the hunger of menopause that actually as hormone levels fluctuate, we become hungrier. And that's actually because ghrelin and leptin are actually changing as hormone levels fluctuate. So the hormones that drive our appetite are actually fluctuating. as our estrogen levels fluctuate. So again, this is where the GLP ones will actually become, I think, useful for many, many women. And I think they've kind of radicalized some of the midlife weight gain for women that are doing all the right things, but your metabolism is so disrupted.

And you can't undo some things that when damage is done, you can't always undo it with lifestyle, right? There are some things that do occur that you can't undo. You can stop them from progressing, but you can't stop. You can't reverse the issue. And the GLP was. Meaning like some kind of metabolic disregulation? Yeah. So there's been some really, I think, really elegant studies that have been done in mice.

And I know mice aren't humans, but we can extrapolate and they can provide us a foundation to hypothesize from with humans. But there's been some very elegant studies that show the metabolic changes which occur with estrogen depletion in mice. And one of the studies I found was so interesting was that there's pancreatic damage, actually with lower estrogen levels, so the pancreas didn't produce insulin the same way. And you could give those mice back,

and they became insulin resistant. And you could give these mice back estrogen, and it reversed some of the metabolic changes, but not all of the metabolic changes. So it kind of highlighted to me that you can cross a threshold with some metabolic issues that you just can't undo. So perhaps as estrogen levels start to go down, there's metabolic disruptions that we just simply can't undo,

that the GLP ones help us. us undo. And this is also where early estrogen intervention becomes really important, because if we prevent some of this metabolic disruption, we have less catch up to do, right? So, but for a midlife weight gain, for the woman who's doing everything right, for some women, they'll be totally helped and they'll be totally great. For many women, though, they won't, they won't be totally helped. And I said, like I said, this is where a GLP1 comes into play. Estrogen can help with body composition. it can help with hunger, it can help with body composition. Are you going to radically lose weight or radically shift your body composition with it?

Probably not, but it can be helpful also. And we know that when we combine estrogen with GLP-1s, that you do, that they work. The GLP-1s work a little bit better. What role does supplementation play? In terms of brain health protection, a multivitamin has been shown to be protective. The Cosmos trial showed that individuals. who took a multivitamin had better brain health protection. So I'm actually, I'm a supporter of multivitamins for women.

They don't prevent cancer. They don't prevent other issues, but they do prevent, they do have been associated with better cognitive performance. Omega-3 fatty acids, super, super important. They decrease inflammation. They are actually omega-3s are extremely important for women's midlife brain health also. Women with dementia have lower levels of fatty acids. actually. So that's probably in play in terms of dementia. So it was recommended an omega-3.

Creatine gets a lot of play. I was wondering whether you were going to, if you didn't bring it up, I was going to ask you about it because there's obviously, you know, a lot of discourse right now around the protective, you know, brain protective aspects. Yeah. Creatine is like the one supplement that's been the most like proven benefit, right? And I think as we get more information, I mean, certainly supporters of creatine in terms of brain health currently. But, but, but, but, body mass and muscle building, yes. Then, co-Q-10, if you're on a statin, you want to check your co-Q10 levels. You want to make sure that those are adequate, not only from statin-associated myopathies or muscle pain, that type of thing, but also with brain health, making sure that's a...

And then, of course, you want to look at deficiencies, right? Many individuals are vitamin D deficient, so vitamin D supplementation if you need it, B12, folate supplementation, if you need it. In terms of supplementation for just metabolic health in general, I don't know that there's one supplement to recommend, you know, berbering some people are fans of, that type of thing. But again, you know, the GLP ones are super, I've been super, super, super, super, super, super beneficial for women who have real body comp issues. Pharmacologic intervention is probably going to be the most beneficial. Obviously, environmental toxins can impact hormone regulation.

So what do you have to say about the environment in which, you know, we live in the impact of our consumer choices and our habitats upon. our ability to optimize our hormonal health, and in particular, obviously, for somebody who's going through paramedopause or menopause. So I think it's really important to pay attention to. I think we can't obsess about it, right? Because if you obsess about it, you'll drive yourself crazy, right? I mean, that's like your CGM or you're wearable, that type of thing.

But I think you should be cognizant of it. And really, because I do think that thallates, BPAs, paraben, organopesticides, they have been demonstrated to be endocrine disruptors. So I think to minimize our exposures is really, really, really important. I mean, I think, you know, getting a good water filter is important, making sure that your cosmetics that you use, that you put, you wouldn't think of cosmetics as being absorbed, but they're totally absorbed, being phallate-free and... Greg Renfrews counterproducts. Yeah. Do you know Greg? Yeah. So, yeah, so, you know, don't drink out of plastic. I mean, all the standard things.

think, though, to be very aware of it is important. I think to, again, we can't obsess about it. I think to obsess about it. I mean, I went through a period where I obsessed about and drove myself totally crazy. Yeah, totally crazy. And I could see that. You're, you're controlling your environment, right? Yeah, I'm totally. Yeah, I'm getting into the level three biohacker soon, you know, I made the decision that I was going to have good, healthy longevity. And, but, but, I think that it's important. It's easy not to drink out of plastic. It's easy to avoid parabins and thallates.

Candles are another big one, you know, making sure that you don't have a candle full of thallates, you know, and fragrance. And so, again, I think they're important. And I think that we've shown that they're important. As I said a few minutes ago, like all of these things are just good for overall health. And they're also, you know, like health span promoting. And, you know, longevity is an aspect of your practice. practice and something that you're fairly steeped in.

I know that you said like that your goal is to live to like, I don't know, 150. 115. I want to see what happens. There's too much going on. It would be fun to kind of explore parsing fact from fiction in this longevity world because there's, you know, there's a lot of energy around this right now and some interesting scientific breakthroughs and developments and everybody's paying attention to this.

We all want to live longer. But there's a lot of nonsense out there also. And so as a clinician and a scientist, like, where do you draw this line? Like, where should we, you know, invest our attention and where's the nonsense that we can dismiss? I think where we need to direct our attention is to getting data. I think that there are some very interesting longevity strategies out there, but we need to get the studies done and get the data. But I think what is foundational and what I kind of, I think is so interesting, I, I read these studies, I don't know, probably 20 years ago about Centurians.

We knew Centurians 20 years ago. They were all optimistic, right? I mean, we had, there was like, this is not new information, but it's positive thinking people. Yeah. And I always say to pay attention to longevity, you have to start with good preventative health care, right? You need to make sure that you get your blood pressure check, make a lipid check, make sure you do, you know, it's not going to be a magic pill that you're going to take. You're going to have to have good lifestyle intervention. So you've got to go back to that good primary care of medicine.

It's not the answer that people want to hear, right? you got to get your blood pressure check, get your lipage check, get your CBC check, get the basic foundational things, get your vitamin D check, get those basic foundational things, get those under control. And then with lifestyle, get those under control, get your lifestyle under control, get your nutrition, your mindset, your movement under control, because you can do none of the movement in the world, you take a bunch of peptides, right? You're probably not going to get the benefit from any of it, right? So making sure that you move, that you pay attention to nutrition, stress managers, fleet It sounds, it's just like a record recording, right, over and over.

And then if you want to look into the more what I call experimental strategies, right, well, that's maybe microdosing a GLP1, right, for brain health or cardiac health, and that data is emerging and we're getting it. Definitely GLP1 is for metabolic, for body comp. Important though, if you're going to begin to look into a GLP1, though, for brain health protection or cardiac protection that you look at your body comp, because you will lose muscle with a GLP1 if you don't string strain and you don't eat protein. So a responsible practitioner will look at your body comp before prescribing a GLP1 to you or talking to you about a GLP1 in the longevity space too also in terms of making sure that you have adequate muscle mass and that you don't tilt into a worse body composition.

And then when you begin to look at like NAD and peptides and other IVs and other interventions, I think they're all really interesting spermadine as one, but we need the studies. And this is what are being done. Like, we are beginning to do some studies and beginning to look at some of these longevity strategies. You're going to have to look at surrogate endpoints, right? And what are those surrogate endpoints? But you're not going to look up, you're not going to do a course of the study over, like, you know, 30 years looking at it in terms of, I guess you will that will be part of it,

but you'll have some surrogate endpoints to look at. So you're going to have to look at, do you look at a biologic clock or what are you, you know, are you looking at proteomics? Are you looking at organ proteomics? I mean, these are the questions. These are the big questions that I think. real good, reputable people now are getting involved in. And I think this is what you're seeing in the longevity space now.

It used to be kind of the wild west. It still is in some ways. But also there's people now who are really beginning to investigate these strategies. And we need them looked at in a scientifically rigorous fashion. And I think we'll find out that some will be beneficial and some won't be. And a really respected individual in this field kind of said something to me one day, which really resonated with me. You know, when we're young, we're building, building, building.

When we're older, we kind of plateau, and then we fall off a little bit. What we're trying to prevent is not falling off from that plateau. So we don't necessarily want to be in a big building phase when we're older. We just want to stay kind of neutral when we're older. We just don't want to fall off the plateau. So we need to look at these strategies through that lens also, too, in terms of what are we trying to accomplish here, right? Are we trying to accomplish the cellular mechanics of a 12-year-old?

Probably not. We probably want the cellular mechanics of somebody who hasn't fallen off the cliff yet. So I think that these are the big questions that are being asked right now and are beginning to be answered. Is there any emerging development or protocol or scientific breakthrough that excites you or you feel is promising? Like to kind of push you on something specific? Well, I go back to the GLP ones, right? I sound so boring, but it's a peptide, right? But, you know, these are drugs that are, the more we study them, the more we're finding through their anti-inflammatory nature, how beneficial they are.

As an example, so I was an endometriosis surgeon when I was doing complex pelvic surgery. So I had a number of endometriosis patients. So endometriosis is a debilitating disease for women. that leads to chronic pain is where the endometrial cells inside the uterus are abnormally positioned on the outside of the uterus. They become extremely inflamed. And we're beginning to think of endometriosis as a disease of inflammation. And so we noticed early on that in our endometriosis patients that we were using gLP ones on that were overweight because a lot of endop patients have a little bit of extra weight. So we began to prescribe gLP ones for our patients for weight loss

more than anything else, but before they lost weight, their pain got better. They were like, oh, my pain is better for the first time. So we realized early on that this big anti-inflammatory component of GLP-1s, so the more we study them, the more we see these anti-inflammatory components or actions of these, this category of medications. And aging is a disease of inflammation, immuno-inflammation, and mitochondrial disruption, right? So those are the foundations of aging and cancer and dementia development. So the GLP ones are hitting that inflammatory component of the aging pathway. So I think that the more we look at those in terms of brain health protection and cardiac protection. And then just in terms of immunomodulation and such, I think

as we look, there's not one specific breakthrough that I see right now that I'm super excited about. I think I'm excited about the field because we're beginning to put some scientific rigor into it to get some good answers. We lack enough education and awareness around these women's health issues for women. But I want to talk about the dudes because, like, we're just, you know, stumbling around in the dark here, you know, where I want you to provide some, some advice and some guidance to the men out there who are in partnership with women and want to be, you know, there for them. Like, what do we need to know?

Because, like, I don't, you know, like, I've just learned so much today that's going to be helpful in my relationship with my wife. What do you think the men need to know about the women in their lives who are going through this phase of their life? I think that there are, the men need to know that there are real changes which are occurring. That these are real physiologic changes that can impact mental health, mood, libido, I think that to be empathetic with those changes is really important to realize that the changes that they may be seen in their partner, whether it is pelvic pain, painful intercourse, mood disruptions, lack of sleep, stress, irritability are not usually not driven by a relationship or a partnership, but are driven by real true physiologic changes. And then I think to make sure that your partner actually is getting the appropriate care is important. And that may be just making sure that individuals making progress in terms of management of some of these issues. But I think to be empathetic is really, really important.

I think to realize that it's not a product of a relationship or a partnership, but it's a physiologic change that's occurring. and that there's answers to those physiologic changes. How do you know the difference between when the behavior is due to a hormonal shift and when the behavior is actually something else? That's a tricky one. Maybe we need a psychologist for that one. Yeah, I don't know. It's like reading the tea leaves.

Yeah. There's something called gynechiatory, actually. Oh, really? What is that? So that's a term that we coined, actually. We need to understand the vagina from a psychological perspective. There's a lot of psychology in women's health, right? Just by the nature of how hormones impact the brain.

I mean, they change your neurotransmitters. You know, progesterone is calming to the GABA transmitter, right? I mean, it works on GABA transmitter, which is the calming transmitter. Estrogen impacts serotonin, dopamine, and GABA. So there's real neurotransmitter changes. So what I would say is if nothing in the relationship has really changed or nothing, Nothing in the life is really, nothing in life is really changed. And life is looking pretty good on the outside, but on the inside it's not looking so good.

It's probably the physiological or hormonal shift. That's one way to look at it. You recently started a podcast, Decoding Women's Health. Congratulations. I mean, you've only, like, it's only been a couple months, right? Yeah. So you're brand new to this whole world. Like, how is it going?

Like, why start a podcast? What is the mission behind this? So women need the right information. They need good information, right? So they need information from the experts. And so on our podcast, we are going to the experts in their field to get information. So if you want cardiac information on midlife, we're going to talk to a professor of cardiology. So we're trying to get like the real experts involved in women's health and get the real

foundational information to women in a platform that is widely available to them because so much of the information right now is misinformation. and so much of the information that is on a platform that's accessible to women, because women aren't going to go read the cardiology journals, right? But I can get to the person who's writing those studies who can really, we can interpret that information and provide that information to you to impact your health. So we're trying to get the real vetted, scientific, medically actionable, and information to women that is the scientifically data-driven information, but in a progressive manner.

I mean, we have a progressive view in terms of an open mind, obviously, and that type of thing, and driving the information and conversation forward because the expert in brain health is not going to probably be talking on Instagram, but we're going to make sure that you get that information in a social platform. There's such a need for this, you know, to have powerful women's voices talking about women's health issues, specifically, you know, the female, you know, Huberman, you know. You were going to laugh on some level. I think it's fantastic. I'm just jealous that you went to Pushkin and you didn't come to us because I would love to work with you on this. And I think it's fantastic what you're doing.

Yeah, thank you. It's definitely we are fighting a good fight, I think, and we really want to get the information out there to women. So in a way that it's accessible and actionable. So parting words before we wrap this up, you know, what is the message that you want to lead? Eve with the woman who's watching this or the man who's trying to understand, you know, women better about this phase of life and the agency that, you know, we can leverage to live better and longer. Yeah, I mean, I think that that you just said it.

I mean, it's the agency that we have. I mean, we do have agency. I think that so much, so much of the time, we just get busy with our lives and we're like, oh, I don't feel so great. You know, this is just the way I feel and almost just like just fall into it and go with it. Resignation. It's like, well, this is just what, this is how old I am and this is the way that it is.

Yeah, and you can feel great and you can rock any age and feel great at any age. And I always say it's health optimization and living your best health possible. I mean, we all come from different foundations of health. Like if you have autoimmune disease, you're definitely going to have some days where you don't feel so great. And if you, you know, have a GI disease or cardiac disease, you know, you're going to come from a different baseline. But everybody can feel better.

And so I think that that agency to feel better and live longer and live healthier and enjoy that great health span is within everybody's grasp. No matter where you're starting from is within everybody's grasp. Cool. New book coming out next year sometime? Yes. Yes. Yes. All right.

Well, will you come back and share about that when the book comes out? I would totally love to do that. Yeah, totally, totally do that. This was great. Again, I'll just close with what I said at the outset. I really do think you're a vital voice in this discussion around health. And I appreciate you coming here today. I so appreciate you. I appreciate you allowing me here today.

I appreciate you allowing me to speak today and to speak with you today. And I appreciate you getting the word out there. So great. All right. Thank you. Until we talk again. Yeah. Cheers.

Cheers. All right, everybody. That's it for today. Thank you so much for listening. I really do hope that you enjoy the conversation. To learn more about today's guest, including links. and resources related to everything discussed today, visit today's episode page at richroll.com

where you will find the entire podcast archive, as well as my books, Finding Ultra, the voicing change series, and the plant power way. If you'd like to support the podcast, the easiest and most impactful thing you can do is free, actually. All you've got to do is subscribe to the show on Apple Podcasts, on Spotify, and on YouTube,

and leave a review or drop a comment. Sharing your show or your favorite episode with friends or on social media is of course awesome as well and extremely helpful. So thank you in advance for that. In addition, I'd like to thank all of our amazing sponsors. Without him, this show just would not be possible, or at least, you know, not free.

To check out all their amazing product offerings and listener discounts, head to richroll.com slash sponsors. And finally, for podcast updates, special offers on books and other subjects, please subscribe to our newsletter, which you can find on the footer of any page at richroll.com. Today's show is produced and engineered by Jason Camiolo, along with associate producer Desmond Lowe. The video edition of the podcast was created by Blake Curtis and Morgan McRae with assistance from our creative director, Dan Drake. Content management by Shana Savoy, copywriting by Ben Pryor.

And of course, our theme music, as always, was created all the way back in 2012 by my stepson's Tyler and Trapper Piot, along with her cousin, Harry Mathis. Appreciate the love. Love the support and I'll see you back here soon. Peace, plants.