unPAUSED with Dr. Mary Claire Haver - How Menopause Changes Your Gut Health with a Leading Gastroenterologist

Episode Date: October 6, 2026

In this episode of unPAUSED, recorded on location at the Aspen Ideas Festival, Dr. Mary Claire Haver sits down with Dr. Trisha Pasricha, neurogastroenterologist at Beth Israel Deaconess Medical Center, assistant professor of medicine at Harvard Medical School, and author of the new book You've Been Pooping All Wrong. Women in perimenopause and menopause who describe bloating, new constipation, or digestion that suddenly feels unfamiliar are often told it's stress or age — Dr. Pasricha explains the real biology, starting with the estrogen receptors inside the gut's own nervous system, and makes the case for treating the gut as a second brain rather than plumbing. She breaks down why IBS affects women about twice as often as men, and why women with gut pain are so often told it's all in their heads — in her words, it's not the stress causing the symptoms, it's the symptoms causing the stress.They cover the less obvious causes of bloating — including pelvic floor dysfunction — accidental bowel leakage after menopause and how it's treated, the link between smartphones in the bathroom and hemorrhoids, what to expect from GLP-1s, and why women treating iron deficiency can often take oral iron every other day to ease constipation. Then it's the serious part: the four colorectal cancer red flags women should stop normalizing, which stool colors need attention, why colonoscopy is the only screening option that prevents colorectal cancer, and why new bloating after menopause should always be evaluated. The practical takeaways include daily fiber targets, the case for psyllium and fermented foods, why ramping up fiber slowly prevents gas and bloating, a realistic approach to cutting ultra-processed foods — and the habit Dr. Pasricha asks of her own patients: look at your stool every day, because knowing what's normal for you is how you notice when something changes.Guest links:Dr. Trisha Pasricha (Website) https://www.trishapasricha.com/Dr. Trisha Pasricha (BIDMC Gut-Brain Institute) https://research.bidmc.org/gut-brain/people/team-member-1Dr. Trisha Pasricha (Instagram) https://www.instagram.com/trishapasrichamd/Dr. Trisha Pasricha (TikTok) https://www.tiktok.com/@drtrishapasrichaGut Checker (Substack) https://gutchecker.substack.com/Ask a Doctor (Washington Post) https://www.washingtonpost.com/people/trisha-pasricha/Books:"You've Been Pooping All Wrong: How to Make Your Bowel Movements a Joy," by Dr. Trisha Pasricha https://www.penguinrandomhouse.com/books/776380/youve-been-pooping-all-wrong-by-trisha-pasricha-md-mph/"The New Perimenopause," by Dr. Mary Claire Haver https://thepauselife.com/pages/the-new-perimenopause-book"The New Menopause," by Dr. Mary Claire Haver https://www.amazon.com/New-Menopause-Navigating-Through-Hormonal/dp/B0CKBZ4K1Z

Your gut is a brain. A lot of these diseases start in the gut years and years before that disease itself manifests. You have identified four colorectal red flags. The obvious ones is bleeding. Abdominal pain. Change in your bowel habits. And then the last thing is iron deficiency anemia. This is a big one.

It's not the stress causing the symptoms. It's the symptoms causing the stress. Yes. The key to why IBS is more common in women than in men is that estrogen plays a critical. role in pain signaling from your gut. The interesting thing is that we can treat it, though, with pretty good accuracy. The views and opinions expressed on unpaused are those of the talent and guests alone and are provided for informational and entertainment purposes only. No part of this podcast or any related materials are intended to be a substitute for professional

medical advice, diagnosis, or treatment. I've heard this from a thousand women. Her gut has turned on her, bloated by the afternoon, constipated in a way she never used to be, and every doctor has told her the same thing. It's stress. It's your age. It's in your head. For years, I didn't have a better answer. The gut was not in my training. When a woman in perimenopause told me that her digestion was falling apart, I filed it under stress, the way we file almost everything women bring to us. And then I found today's guest. And she was saying, the data to back it, that none of this was ever in our heads. Estrogen receptors sit inside the nervous system of your gut.

When estrogen drops, your gut slows down and starts feeling pain it used to ignore. This is biological, not psychological. Dr. Trisha Pashrucha is a physician scientist at Beth Israel Deaconess Medical Center and an assistant professor of medicine at Harvard Medical School. She writes the Ask a Doctor column for the Washington Post and is the author of the book, You've Been Pooping All Wrong. As a neurogastroenterologist, she proved the gut is a second brain and documented that medicine dismissed these symptoms in women as hysteria for over 100 years. Today, we take that back. Let's get into it. I'm Dr. Mary Claire Haver, a board certified obstetrician

and gynecologist and certified menopause practitioner. I'm also an adjunct professor. I'm also an adjunct professor of obstetrics and gynecology at the University of Texas Medical Branch. Welcome to Unpaused, the podcast where we cut through the silence and talk about what it really takes for women to thrive in the second half of life. This episode of Unpause with me, Dr. Mary Claire Haver, is brought to you by Alloy Health. One of the things no one really prepares you for in your 40s and 50s is how much your skin can change. And it's not simply aging.

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practice every day. Head to Withings.com to learn more and use promo code Unpaused for 10% off. Consult your physician before starting any new health or fitness regimen. Dr. Trisha Pasricha, welcome to Unpaused. Thank you so much for having me. I'm so happy to be here. So those of you who are watching this on video, we are in a very unique location behind us. We were at the Aspen Ideas Festival, and she was kind enough to agree. We're both speakers here to have this podcast opportunity with me. So I'm so happy to have you. I've followed you on social media for probably two-ish years.

Oh, my gosh. Love everything you're doing. Your book, I can't wait to talk about it and dive in. But let's start talking about gut health. This is one of the most requested topics we have from our listeners and our followers. What is a healthy gut? What does that even mean? Yeah.

Oh, great. question. Gut health is a term that is so fraught in some ways because I think traditionally we've defined gut health as the absence of disease in academia, in medicine. And I think we're learning that gut health is a lot more than just not having a disease at this point in time. And part of that's because we're learning that a lot of the diseases that don't even seem to be related to the gut, like Parkinson's disease, which is what I study. A lot of people think that's so odd a gastroenterologist studying that. But a lot of these diseases start in the gut years and years more. before that disease itself manifests.

And it's just sort of brewing quietly in the gut. So a healthy gut to me and gut health means you are laying the foundation for longevity to prevent the disease from ever occurring in the first place. And a lot of that has to do with diet and lifestyle and even things that we don't necessarily connect again to the gut, like stress management, for example, like hormones, like all of these exciting things that I know we're going to talk about. Yeah. I learned zero about this in medical school.

and absolutely nothing in residency. It's, it's, we share, you know, your gastroenterology, I'm OBGYN. Our areas are literally laying on top of each other. Totally. And the anatomy. Close neighbors, yes. And I learned little to nothing other than how to not open up accidentally in surgery. Yes.

How to avoid the gut and who to call if you did it, you know. Right, right, right. And so I was looking at an image of the perineum this morning. And like, literally there's a perineal body we both share in our areas of expertise. Yeah. And we don't have this conversation as often as we should, do we? Okay. So you've said, and your book, talk to me with the title of your book and why you chose it.

Yeah. Oh, you've been pooping all wrong. Yeah. Yeah. It's a conversation starter or a conversation stopper that title, depending on who you're with. But, you know, I pick that title because it's the phrase I found myself saying so often, either out loud or just in my mind when I was meeting patients because we don't talk about, if we forget about, like, do OB-guyen doctors talk about GI, we don't, nobody talks about GI.

I find, like, you know, we don't talk about our poop because we're so embarrassed by it. And the last time a lot of people ever talked about it was when they were kids, when they were getting potty trained. And then they go their whole lives, never really getting formal instruction on what the science says the right way to do it is, right? Like, yeah, there's a lot of science that says this is the right or wrong way to do it. But you just don't talk about it because we're so embarrassed by it. So this book title, one, the book is like everything I wish I could tell my patients if I had 10 hours to spend with each person. So it's got everything in there. but it's also like a way of just destigmatizing it because a lot of times we skirt around the word.

If we can't even say the word, you know, then we're never going to be able to bring ourselves to just have a comfortable conversation about it. So what about this once a day rule. Is that a thing? Like that's what I was taught or told. And I don't know if my mom told me that or, you know, we talked about a little bit in medical school. But like if you just went once a day, that's all you needed to do and you're good. Yeah, everyone thinks that. Everyone thinks you go once a day and you are close to God and you're that's the end of the conversation. Not true, necessarily. And that's like a big misconception. I think the idea about it was not wrong in some ways. Like there is, your body is physiologically primed to go in the morning.

And so I think that's sort of where this myth starts going once a day. Why? Yeah. In the morning? In the morning, right? So this is something that people don't know. Your gut operates on a circadian rhythm, right? Like you go to sleep.

Your colon actually goes into this very quiescent state. That's so different from your other organs. Your heart's going to still be it. It might slow down. It's still going to beat. Your lungs, they're still exchanging oxygen. Your colon says, good night. It goes to sleep.

And then when it wakes up, you have about an hour to two hours of a window where your colon, when it wakes up, revs with activity. So that's your moment to strike. And then the morning is also when a lot of people, they're drinking their first cup of coffee, right? It's going to make them want to go. What coffee is doing, it's activating this thing called the gastrocholic reflex, right? I did learn about that.

Yes. Very important reflex. Sometimes people are like, I just ate. How can it be that I have to poop the stuff I just ate? that's not exactly what it is. When you eat something, we think it's the mechanical stretch receptors in the stomach that are sending the signal up to the brain that sends another signal down to your cold. So you're just emptying what's already down there. You're not like shooting all that food down so quickly. That would take a long time. But, you know, coffee does this really well. Decaf coffee actually does it. Warm water. Like anything like a big meal that just sort of stretches your stomach can do it. So a lot of people, again, this is why we come back to it once a day is not necessarily the only path to God here. People poop every time they eat.

A lot of people, just a big meal, will cause that reflex, and that's okay. So for me, it's like a little bit less about, did I go once a day? It's wonderful when you lean into your body's own physiology, like when your colon is doing some of that work for you. But, you know, it's going to depend a little bit on how much fiber you're eating. If you eat more fiber, you're meeting your fiber goals, you're going to poop more often. And you should embrace that side of you. Like, that's an okay thing. If you're somebody who has a lot of stress, you might actually poop a little bit less often, a little bit more depending on it.

You're traveling. Your sleep is up. All of these things change. So I don't really focus on once a day. I really focus on how you feel and whether there's a lot of effort. What I don't want is anyone to strain, and I don't want anyone to feel like their social life is interrupted. Like they can't leave the house because they're so worried about that. Those things bother me more than a number.

You know, my area of focus is health after reproduction ends for women. Yeah. And there's a lot of hormone changes going on there naturally. So what should a woman in this transition kind of expect? How are things going to change for her? And when is it a problem? When should she seek attention? Yeah.

People's bowel habits are going to change. And we've studied this. And, you know, as you know, we need a lot more research than we have. The research that we do have tells that there are going to be changes for premenopausal women in the menopausal transition and then postmenopause. And, you know, one of the biggest conditions in GI that I treat is irritable bowel syndrome. That affects about one in 10, maybe even 15% of Americans. So it's a huge condition. Is it more common in women?

Yes. like almost a two to one ratio more common in women. And what is irritable bowel for our listeners? How do you define it? Iritable bowel syndrome, the underlying unifying theme is pain, discomfort, related to your bowel habits. It can be diarrhea. There is a group of people who have more loose stools,

but they have a lot of pain associated with that. It can also be constipation. It's a little bit of a nebulous catch-all term, which is why there's been a lot of misunderstanding about what IBS is. But it's one of those things that is very common in younger women, and it tends to get a little bit better, the pain part of it. It's actually related to estrogen levels. It gets a little bit better as we age.

But that doesn't mean that the bowel habits don't change. Sometimes people, as we age, we all tend to become a little bit more constipated. For some women, and this is pretty common, we start to develop fecal incontinence. That becomes significantly more common as we age. That is one of those things that we don't want to talk about. But that's common in post-in-postment model. I mean, really for our listeners, what is fecal incontinence? Yeah.

You know, people prefer the term accidental bowel leakage, but basically it's like when you poop your pants, right? Like it happens in postmenopausal women, it happens to people about one to two times per month. That's the average for women. So it's huge. And so, I mean, just think, first of all, like I love talking about this topic. One, because I've seen how much it can really hurt somebody's social life and they're so embarrassed about it. So I really think it's important to normalize these conversations. If you think, wait a minute, the average for a postmenopal woman is like one or two times a month. that means it's happening to all of us, right? And so, like, you shouldn't feel so isolated and so embarrassed and especially so mortified to even talk to your doctor about it. You know, it's one of those things that we can actually treat, but we do such a poor job in medicine, I think, of reaching women and getting them to open up and tell us about it. And obviously, people don't necessarily want to bring it. They'll talk about diarrhea. They'll talk about constipation sometimes. But there really, it takes a lot to be able to say, you know what, every now and then I wake up in the morning and there's a stain there. I don't know how that happened. Or I coughed. And, and, you know, I couldn't control it. That's important to talk about because we treat it differently and there is treatment out there. So is this related to pelvic floor, childbirth? You know, I did learn that in residency. We had a, you know, section in Eurogonecology. What we learned about the damage the pelvic floor undergoes when we push eight, nine, ten, seven pound babies out of our

perineum and it stretches and tears and rips things that used to hold all of that in. But does this happen outside of just childbirth? Yes. And actually, I think, This is something that a lot of people, I think, get confused about because we call some of the issues that we deal with in GI, really in this area, pelvic floor dysenergia. And a lot of times people are like, oh, you know, like I had some pelvic floor dysfunction related to the urinary symptoms. This is different. A lot of this is related to the anal sphincter. And right after childbirth, fecal incontinence, accidental bowel leakage is pretty common. Yeah. And I tell patients to expect it to some degree.

Totally. Yeah. And often that period where it's happening, it gets better. over time. The problem is that then there's this like second wave that occurs later in life for women. And there is, there does seem to be a link to whether you've had a traumatic, in any form, injury from birth. Like maybe there was like a small terror that reached the anus. Maybe it was using forceps, something like this. That does seem to increase your risk. But not always. Like there are a lot of, like you can get this even without. Some of it is age related and related to the sphincters. The sphincters, if they become a little weaker and that can happen from neurological disease, it can happen from diabetes, it can happen from anal intercourse. If the

synchters are a little bit weaker, then you're at higher risk of fecal incontinence. And so the interesting thing is that we can treat it though, like with pretty good accuracy. We can treat it either by saying, what's causing that increased push? Is there some increased diarrhea? Is there looser stools that we need to stop and address? We can do that? Or do we need to do something to kind of increase the integrity of the sphincter? We have dedicated pelvic floor physical therapy with this technique called biofeedback you might have heard of. That's the technique that's been shown to be really effective in not only pelvic floor dysfunction, but also in fecal incontinence. And it can really help people. The other thing that really

helps fecal incontinence is taking fiber, specifically cillium husk has been really nicely studied. And the nurse's health study from Harvard, they looked at cillium husk and fiber intake. And that seems to decrease those because we think it's, you know, the fiber not only can it bulk up the stool. But we think that when those microbes in your gut process and ferment it, it can actually heighten the sensitivity of the receptors close to the sphincter. That actually helps say, wait a minute, we recognize that there's some incoming tidal wave. Let's close the dam. And it does. Wow. Yeah. Let's talk about bloating. Yes. Huge, huge topic. That is one of the top concerns that women go through the transition and they are struggling. I've changed nothing in my

diet. Yeah. I've changed nothing in my exercise. I've changed no new stressors in my life. The only thing we can pinpoint is she's going through the menopause transition. Yeah. And now she's dealing with bloating and cannot understand. First of all, what is bloating? Yeah. A million dollar question. Bloading is, you know what? It's one of the most difficult symptoms to treat even within GI. I think it's difficult and it's misunderstood. And I think part of the reason is that, you know, we need to do more research on it. But what we know is three things. One, bloating can be related to your diet. And like you said, a lot of people haven't changed their diet.

So usually by the time someone's seeing me, we sort of know it's probably not necessarily diet related. But for someone who is thinking about what are those things, it's things like crucifers, vegetables, beans, these things can increase bloating for anyone. The second thing is, well, is it actually a subtle change in my bowel habits that I may or may not have even perceived? That's actually the second most common cause of bloating. And surprisingly, pelvic floor dysfunction, which does happen more and more with age, very common in women, is a cause of bloating. And it's an underappreciated cause of bloating.

And the way I describe it to patients is, well, think about your body like a box. Think about your abdominal cavity like a box. Okay, so all bloating is, is something that is causing the front of that box to push out. And sometimes the problem is there's something from within pushing out. Sometimes the problem is that the bottom of the box is or is not moving appropriately. Sometimes it's the top of the box, the diaphragm. that muscle. So actually one of the treatments for bloating that I think is like the third and least appreciated is something called abdominophrenic dysergenertia. That's a big word. But what this is

referring to is the phrenic nerve in the diaphragm and the idea that there's actually nothing new. It's not gas. It's not necessarily stool. There's nothing pushing that box outwards. It's simply that the abdominal wall muscles and the diaphragm are not coordinating. So the box is just flattening out. It's pushing out on its own. And the problem is in the abdominal wall. Now, this hits for a lot of women because this is something that our muscles in general get a little bit weaker, where you need to retrain them. And people do really well with something called abdominophrenic therapy. Biofeedback. Yeah, it's the same kind of thing where you put sort of electrodes on your stomach through a physical therapist and they kind of work

to retrain those muscles. And diaphragmatic breathing, like the kind that opera singers do, can actually also help with bloating. So this is like the third, I think, most underappreciated of bloating, but it is something that we see all the time in my field. So if you feel like you've tried everything, you've tried everything with changing your diet up, make sure you've investigated, really, are my bowel habits changed or not changed? Because sometimes that pelvic flow disnergia is subtle and it's hard to appreciate that that's the cause. But if you've done that, you've looked into it, think about abdominal frenic disneria. Think about the fact that it actually, it actually could just be my abdominal wall and I need to strengthen and change those muscles.

on social media where we both have homes second homes i see a lot of blame for bloating going towards shifts in estrogen is there any truth there and shifts in the gut microbiome i don't think we have the data to say yet that i mean i think there's a lot of blame it's it's it's easy to oversimplify okay the microbiome and i think we see this in every disease field where we say well you know, the reason you're at higher risk is the microbiome of the X disease. And, you know, eat this food, it's going to change your microbiome. Now, that is not to say that the microbiome is not necessarily related. Like, all of it is related. But it's too soon for us to say, okay, we know the exact mechanism we've pinpointed. I mean, it's only within the last five years that we've even really pinpointed the role that estrogen plays in IBS.

I mean, all of this data is so emerging, which obviously bloating is a big part of that. So it's too soon to say, like, oh, yeah, here's the one thing you need to do to fix your microbiome. that's going to fix your balloon. Glute is hard to treat. But it's often a multifactorial approach that we take and we can make a difference there. So walk our listeners through where estrogen and gut health kind of intersect,

like microbiome, the esterblone, without even a thing. First time I read it, I was like, does someone make this up? But it's everywhere now. So like, why does our gut change across the menopause transition? Yeah.

In relation to your female hormones. Yes. Well, this is, I think, really cool. And I think, again, there's been a lot of misinformation about this simply because it's still an emerging field. But here's what we know. First of all, our gut microbiome, as you know, it's like shaped probably most profoundly early in life in this first couple of years, like how we're born when we transition from being breastfed or formula fed to solid food. But we're now learning that there is this other shift that happens in our younger adult years around the time of puberty. And that's when we start to see that the microbiome starts to differ between. young boys and young women, right then and there. And then as we grow older, it continues to change. And we have a number of studies that show that between premenopausal women and postmenopausal women, there are changes in the microbiome. We know that. They lose diversity. Yes. Right. Yes. And diversity. I'm glad you brought that up because diversity of the microbeum. Yes. Yeah. Yeah, alpha and beta diversity. These are so important when we're thinking about the microbiome because you don't just want a microbiome that has like two or three really healthy bacteria. You want a

diversity of bacteria in there. And that's because different bacteria, one, serve different roles. They do lots of different things, but they also ferment different kinds of fiber. Everyone thinks fiber is the same thing. Like there's lots of different kinds of fibers. Some bacteria ferment some better than others. But related to estrogen, what we've learned about the esterbolon, which is a really cool area of science, is that, you know, when your body, so to speak, this is simplifying it, but when your body's sort of done with the estrogen that it has produced, you can conjugate it, meaning your liver puts this molecular sort of tag onto it. And then that says, okay, great, it's ready to be excreted in your poop. It'll enter your intestine and it'll exit.

What we've found now is that some of the bacteria that are living in your colon have a way of deconjugating that estrogen, meaning it like takes that little molecular tag off so it can get reabsorbed and it comes back. Now, how cool is that? Because in a way, it's like, wait, okay, we're recycling some of that estrogen. Maybe this is a good thing. And in some cases it probably is. And what we don't know yet is in whom do we see these bacteria that have that capability to modulate estrogen. Why, for some people, is it higher, is it lower? Is it necessarily tied to menopause? Is it not? And what role does this play overall in our health? We don't quite know those answers yet. What we do know is that some bacteria not only can deconjugate, meaning they can give you back some of that estrogen, but some have receptors themselves

for estrogen. And so they are using that estrogen themselves. And then that has other functions and changes right there in the gut lining, but that ultimately help other parts of your body. So it's an emerging field, I think, again, it's like one of those areas that it's very exciting. We are all can't wait to study this a little more, but it's a little bit too soon, unfortunately, for us to be able to say, like, we have the cure or the way to change a lot of what's happening right here and day, but I think like in 10, 20 years we're going to get there. I know that it feels like a long time, but I'm actually very optimistic about this. I'm, I think that's, you know, reasonable. Now, the other thing we've learned about estrogen, which is really important in my field, and I think

the data is much more firm about is that the role that estrogen plays in pain signaling. Wow. I think we don't, yeah, right, we think about hormone. We know that estrogen in the gut, it tends actually to slow down motility. So people who take, for example, hormone replacement therapy, postmenopausal women, they actually find sometimes that their gut, their stomach slows down. It empties a little bit more slowly. We know that it can cause a little bit more constipation.

So sometimes that's why we think, well, maybe younger women often have a little bit more constipation, but then as we get older, there's other factors that lead to that even as the estrogen levels drop. But what we learn now, which I think is sort of the key to why IBS is more common in women than in men, is that estrogen plays a critical role in pain signaling from your gut. So without estrogen, you actually don't perceive and process pain as strongly, right? Like when it comes to pain, men and women are not equal. We have never been equal. Numerous studies have shown that women experience more severe pain. We need more analgesics. We don't have the same bodies. Estrogen is part of that story. So estrogen, and this was a big set of studies that have come out over the last

five years, estrogen in the gut stimulates some of the cells that produce serotonin, all right there in the lining, that then send signals up to the sensory nerves of the gut to the brain saying, we are in pain. And in mice, if you take out the ovaries, suddenly they don't perceive pain from the gut as much. And if you inject estrogen back in, then suddenly they do perceive that pain coming from their gut. And we think that that's why a lot of younger women have IBS. As women get a little older, a lot of times that discomfort and pain part of it gets a little better, even though maybe their bowel habits aren't, there's different changes there. But the way they perceive it. But the way they perceive gets better. And some of that can be,

we think, linked to this loss of estrogen with life. And would estrogen replacement? Have we looked at that? Yeah, we looked at it. And I know there's big, what our listeners are starting to learn as I'm learning is there's a big difference between endogenous estrogen. Of course. And hormone replacement therapy. Yeah. Right.

We can't expect them to do the same jobs. Not all estrogens that we, you know, pharmaceuticals are equal. Yeah. And are they all reaching the part. Yeah. Yeah. They all reaching the parts. I would say it's too.

It's early. I think we hypothesize that hormone replacement therapy delivered in certain ways could change that. Mm-hmm. At this point, though, I want to just be very clear. That wouldn't be the concern about, oh, am I going to somehow increase my risk of discomfort or IBS? That wouldn't be a reason to not do hormone replacement therapy. I'm not seeing it clinically. But again, this is my end of one, you know, with a few thousand patients.

To give you like a sense of how complicated this landscape is, there was a study, a recent one that came out from California that basically said that, yeah, like, IBS does seem to get better in some ways. The prevalence goes down with age. And yet, the women, the post-metabolical women, who have eyes. their symptoms severity is greater than the younger women. Why would that be if I'm telling you estrogen seems to modulate pain signaling? Estrogen is going down with age. Shouldn't their symptoms get better? And this is why the landscape is so complicated, but we think actually, this is a hypothesis, that even though estrogen signaling from the gut has now gotten better with age, meaning you're sending less pain signals up to the brain, estrogen signaling within

the brain has changed in a way that may override that. Because pain, obviously, It starts in the gut, but it ends in the brain. We know we upregulate our receptors because they're scrambling looking for estrogen. We're like, if we have more receptors, then we're more lucky to grab any random estradile molecule floating by. Exactly. And that's Lisa Mascone's work, you know, looking at the brain receptors. And so, you know, I think that's sort of the whole thing about the gut brain connection is you might be able to identify one part of that pathway where you're like, here's to change. This is what's different.

But what you don't necessarily always see in the beginning is how this is having upstream changes. in the other part of that, like in the brain, is it changing? It changes to the brain somehow impacting the gut in a way that you didn't see coming. Fall is finally here. And if you work in health care, you know what that means. Pumpkin spice everything, brisk air and busy waiting rooms. It also happens to be the perfect time for a uniform refresh with new styles and colors from Fix. Lightweight, durable, and ridiculously soft, fake scrubs are hands down,

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Yeah. And or reach for a suppository. Or when should we use this? Is this necessary? Is there ever a good way, a bad way? Yeah. Well, I have two thoughts about laxatives in general. Like, one, you should use them if you need them and your doctor has told you to try them, right?

And I think there's like a big barrier to using them in some sense. Like sometimes people are like embarrassed, a shame to use them. And I sometimes tell people like, there are a lot of people who have slow gut motility and just need a little something from time to time. And that's completely okay. Like we don't shame people with diabetes for taking insulin. Why would we do that? The same is, you know, people need laxatives sometimes to go. That's okay.

There's also been a misconception that laxatives, certain types of laxatives can, some how damaged the nerves in your gut, you can develop a dependence on them. That data hasn't actually really borne out. But on the flip side, I actually tend, if somebody's taking a laxative every single day or multiple laxatives every single day, I tend to hit the pause button and say, wait, what are we missing here? Like, is there, one, is there maybe a different type of medication I can help you with that will simplify all of this and maybe act on a different receptor so that you're not putting yourself through 20 different things and constantly playing catch up? Or two, what am I missing?

You know, like, are you taking laxatives because we're missing the underlying cause of your symptoms? And what would that be? And have we done the right tests yet? So sometimes, you know, while there's no shame in taking laxatives when you need them and they are good tools to have, I don't want someone to just kind of go years and years of taking them without ever just checking in with their doctor, even a specialist like a gastroenterologist, to make sure that you're on the most optimal regimen or that we're not missing something. So let's talk about the perineum real quick, shall we? So the perineum for those of you who don't know what it is, and we will fly in an image on video,

is I think of it everything, the skin area is from the pubic bone to the tailbone. And our areas connect, but I'm literally taught nothing about the perianal tissue. So the tissue around the anus, we kind of stop at the paranoia body, which is that little bit of tissue between the bottom of the vagina and the top of the anus. Yeah, which is where I stop looking. Yeah. So yeah, exactly. I'm like, that's not my area. It doesn't look right, but I'm not.

Yeah, you know. But they're the same tissue and driven by the same thing. So when we go through menopause and we have this GSM, general urinary syndrome of menopause, I think we're missing. So the perianal area actually gets thinner with everything else. Yes. So talk about that. Thank you for talking about this. Yes. So I think, you know, as we age, just like the front part is getting thinner and more delicate and weaker, first of all, even to begin with, I think we don't give this area enough credit. It is delicate back there. And I think we like treat it. It's rough and tough. It's dealing with poop.

It's actually something I think we should be, like, a lot more gentle lid than we are. Well, how should we be caring for it? Wow. Thank you for asking. Well, you know, okay, a couple of things. One, I think about this a lot as a gastrolet. There's, like, more than more people think about this. But I think we need to be a lot more careful with, like, how we wipe, you know?

And so, like, a lot of people, I know. I have really strong opinions about this. But I am team bidet. I'm team bidet. I'm team bidet all the way. Why? Okay. Okay.

Thank you. What is the bidet? Most Americans don't even know what that is. I know. Unless they go to Europe or Japan. I spend so much time on social media debunking. Begames! First of all, the days are for external use only.

This is like a big myth. But all the days are a little nozzle. It can be an attachment that like you just like buy at the Home Depot. It attaches to your toilet seat. Or it can be like a whole fancy toilet. You replace the whole seat. It's heated. It blow dries the area.

So it can go as fancy or as like low tech as you want. But all it is is like a little water spray. And to be clear, it is like a, gentle, like, stream. It's not like this hose. It's not a jet. Yeah, it's not a jet. It's like very gentle.

But the reason I love this so much is because that area gets weaker and more delicate with time. And more and more of my patients start to get hemorrhoids if they get older. They get fissures. If you are somebody who's prepping for your colonoscopy, you will thank yourself for having gotten a bidet. Toilet paper is rough. It's abrasive. Especially if you're somebody who is dealing with incontinence. you're dealing with diarrhea, you are continually causing micro trauma to that area every time you're

right. So if you're going to be on like team toilet paper, you're like not ready for that transition. At least use two plies is like my like, okay. What kind of toilet paper should we buy? Is one better than another? I mean, I judge people who use one play. I'm going to be so honest. I like worry about you. But I use two ply or use wet wipes. Don't throw your wet wipes in the toilet. They are not flushable. Even if it says flushable, they are not flushable. I read not all wet wipes are the same. Some have an hour. alcohol base and that can be irritating. Yeah, I try to use, exactly. Like, I try to use ones that are like just clean, like, as much as possible. But then eventually you get to the point where you're

like, why am I even doing this? I should just get a bidet, right? Like, you'll just feel a lot cleaner. So I like it. I actually, like, got really hooked on to them during the pandemic. I think that's the first time a lot of Americans, you remember the great toilet paper shortage of 2020, of course, as one does. They got hooked on bidetes. But it's something that I recommend to my patients who have Parkinson's disease. I started recommending this all the time because if you have balance issues, whether you have Parkinson's or not, reaching back there, this is like hard to talk about for a lot of people, but that's a big struggle sometimes. And just getting the bidet will change your life. Like, you don't have to deal with this anymore. And like, when I was postpartum and everything's like sore and puffy, I was like, thank God for a bidet. Like you don't have to, like, that's what they teach women to use, right? Is these like pari bottles. It's kind of like that, right? It's just a little gentle stream of water that cleans things up without like any trauma. So I think everybody deserves a bidet and should try it out. And before you not, it, try it once. The ones in Europe are usually these like big standalone separate plumbing devices. That's actually not what we usually have in America. We usually have something that

integrates into the toilet seat. So it's not, you don't have to like redo your whole. It's not a huge bathroom renovation. But I like the discussion about the Perry bottle. I didn't even think of that. We all went home with them from the hospital. Totally. And I was like, and I was like the doctor. And this is the dynamics of this is so awkward, right? You're like, where does this go? With a bidet, you sit there. You press a button. You're not like crouching. You're not moving. You're not like, where do I point this? It goes in the right spot. But I think for cost, I think that's a great place to start. And before you can get a plumber in or by the attachments, is a peri bottle. Yes. Which just basically is a plastic bottle with a squeezy thing on top,

and it just shoots a gentle, very gentle stream. Yeah. Yeah. Of water to the area to help keep things clean. I think we can start there. Totally. Okay. Let's go back to hemorrhoids. Yes. My first introduction to them was having a baby. Yep. And I pushed for, five hours, something ridiculous. I was determined to have this baby. Yes. And, of course, I had a shoulder distortion and a fourth degree tear, all the things.

So that had a C-section with my next vein, and it was all great. But, man. Yep. And that is the gift that just keeps giving. Yeah, once they show up, they do keep coming back. So what is a hemorrhoid? Yeah.

Okay. First of all, we all have hemorrhoids. Hemorrhoids are just these cushions of veins that we actually all have, whether you notice them or not. we all have them. So picture an anal sphincter. Stick with me. Okay. We will fly one in for the video. Right. Amazing. All right. So the anal sphincter, it's like just like a little bit more than like a centimeter or too long. But there's like an internal portion, which you can't see from the outside. And then there's the external portion. There's actually two different type of hemorrhoids. There's hemorrhoids that live on the inside. You can't see them. You could feel them with a finger or you could look at them if you use an eclonoscope or something. And then there's the external ones, which you can always feel. Right in the middle of the sphincter, how we perceive pain and sensation changes. It's called the dentate line. It's this anatomical line. So everything inside of that line, the internal syphincters, on the internal side of it, we don't actually see or perceive necessarily as painful.

We perceive the external ones as uncomfortable, as itchy, as painful. And they can sometimes fill up with a blood clot and thrombose, and those are acut. Very painful. Yeah. No fun. But a lot of us have these internal ones that we actually don't even know that we have until they bleed like stink one day. And we're looking in the toilet bowl and we panic. This is very common after childhood, but there are.

also just common with age and probably the most underappreciated cause of them is straining, just in general, straining, sitting on a toilet, the longer you sit there without pelvic floor support on your smartphone, the higher risk you are of having hemorrhoids. This is what my lab studied a couple years ago. And smartphone users, they are at a higher likelihood of having haemorrhoids than non-smartphone users in the bathroom. So don't take your phone in the bathroom. How long should it Take to poop. I would say, you know, the formal party line is five minutes. I would say, like, in an ideal world, you're in and out in a minute. And that would be like the dream is you have reached a state where you have just, like, optimized your body's response. Like, you know when your colon is contracting. You feel that urge. That urge to go is your colon contracting. It'll do that a couple of times during the day, sometimes predictably, like in the morning we talked about. It'll do it in the morning. It'll do it when you have a meal. It'll do it if you drink coffee. You lean into it. You lean into it. You lean into it. You lean into it. You lean into it. You to that and you go. And you've already primed your system so well because you're eating a high fiber diet. You know, like you have like optimized your circadian rhythm. And so you, so in an ideal world,

less than a minute. That's what I aim for. But officially, five minutes is the limit will give you that. But the more you're sitting there during those five minutes, it depends on what you're doing. Like if you are straining your eyeballs out, I'm worried about you. And I think we need to figure out why you're straining because one, it tells you that, you know, one, you're putting yourself at a slightly higher risk of hemorrhoids. Like the more you strain and do that, part of it. But then it makes me wonder, what are we missing, right, about your constipation? If you tell me, you know, I feel like I'm eating a lot of fiber, I'm exercising, like I drink all the water, all of this stuff, but I get to the bathroom and it just doesn't come out. I'm

straining and straining. I feel like I go, but I haven't completely evacuated. That clues me in that maybe we need to think about the pelvic floor. Maybe we've missed the fact that the problem is not that your colon is necessarily moving so slowly or that you're not getting the kind of nutrients you need in your food, it's that you have pelvic floor dysfunction, and this is underappreciated. But if somebody tells me, I strain for 15 minutes and I've tried all these laxatives, nothing seems to work, I start thinking about it, actually the problem could be your pelvic floor. Wow. For a woman on a GLP1, so many of our patients are now, how does this change things? So like some of my patients will have diarrhea, some will have constipation. I'm always walking them through because we do prescribe to the

appropriate patients in our clinic and our patients are doing really well. But, you know, what should a woman who's on a GLP1, considering a GP1, know about what could change about her bowel. Yeah, it's funny. I have a lot of, we prescribe a lot of these in GI, too, and I have a lot of patients who are like, oh, my doctor said I needed to run it by my gastroenterologist first, because, you know, like I know it can cause a lot of problems. And I really try to reframe that. In GI, we love GLP1s, mainly because we know it has a lot of benefits. It's associated with a low risk of colorectal cancer. My lab found breast cancer, yeah, like 13 different cancers, right? Like, it, I mean, mainly because I think we think that it has more anti-inflammatory properties that we haven't quite unraveled that are not necessarily directly related to the hormonal changes.

But so I think it's a wonderful medicine and I want people from a GI perspective, I always tell my patients there are going to be GI side effects. We should anticipate them. We should plan on them and be aggressive. But let's not let that be the thing that keeps you from getting this medicine that's going to help you in so many ways. And honestly, for some people, for example, I have a lot of patients who have. of irritable bowel syndrome, they have more diarrhea. It goes away when they go on their JLP1, because it actually can slow things down.

So here's what we know it does in the gut. We know it slows down the stomach. And when you have this condition where your stomach is slowed, we can sometimes call that gastroporesis. It can cause gastroporesis. We know it can slow down the colon. So for a lot of people, it causes constipation. But then there's this other group that it paradoxically seems

to cause a little bit of diarrhea too. Usually, though, knowing that most people, one, the GI side effects, they're most common during that ramping up phase. Like as you're kind of finding the right dose and you're going up to the highest dose you can tolerate, that's when the GI side effects are most common. For most people, they peak. The GI issues peak within the first one or two weeks and then they come down.

Okay. Most people don't experience severe or severe constipation. Most people experience some constipation. Is there a difference between the GI side effects on the somaglutide versus the tersepatide? They have tried to look at that. And I think the head-to-head data is not clear that there's like one good winner. And I think it's so individualized to the person. So it's like sort of, I think it's going to be hard to know.

Sometimes we do find, though, that switching one for whatever reason people do better on them. Okay. But usually I would say if you're not already doing this, let's just go ahead and preemptively start you on a fiber supplement. Like let's just start something and see how you do during those first two weeks. And if you're like, wait a minute, I've gone overboard. Like I, you know, there's, I have diarrhea. Like, that almost never happens. But great.

But most of the time people are like, wow, I've become regular for the first time in my life. And that's a great thing. So, and even there's, you know, sometimes when your stomach's less down, it can cause a little nausea. We can treat that nausea. Like, I like to give everybody a fighting chance on their GLP ones. And then, you know, like the wonderful thing is that those side effects tend to be mild to moderate and they tend to go away. Great. Let's talk about symptoms that women should really stop normalizing.

Oh, my God. Favorite topic. You have identified four colorectal red flags. Yes. So walk us through them. Okay. So these are the red flags that have been studied. And if you have three out of four or four out of four in the studies, and this was for early onset

chloroctal cancer, but you had a six-fold higher risk of having chloroctal cancer. And some of them are obvious. Some are really not. So I think the obvious ones is bleeding. If you see bleeding, that's never normal. And you'd be surprised. A lot of people are like kind of normalize it. Like they kind of say like, oh, it's just my hemorrhoids. Yes. And probably like cause one, two, three of bleeding from your bum is hemorrhoids, but make sure you've had a doctor lay eyes on it. Because you don't know, like I said, there are internal hemorrhoids you can't see. Sometimes you think you have a hemorrhoid because you feel a bump there. It's just a skin tag.

It might be the like remnant of an old friend, an old hemorrhoid from two years ago. It's no longer a problem. So just make sure somebody's laid eyes on that. Abdominal pain. And this is one that we normalize, right? Like women normalized, not for our own choosing, but it gets normal. for us pain in some ways. And I never want to normalize pain. I never want to normalize suffering. You know, and sometimes I think we do that to women. Don't we? Don't we all the time? I think

some of the problem is I think we don't talk enough about what is normal and not normal. Like, for example, there are some people who go their whole lives and they're like, yeah, I feel pain every time I eat. So does my mom though. You know, and like everyone, like we all, we just have stomach problems in our family. And like, I think that means the whole family has a problem. I don't think that means that this is normal and this is okay. You know, or they'll be like, well, I get a lot of pain on my period, but so does my sister. Like, it's horrible. We can't go to school sometimes. That's not normal. It's like just the whole family has a problem, you know? We talk a lot on this podcast about the difference between normal, which medically really just

means common. Yeah. You know, under a normal curve, you know, when we look at statistics, but it doesn't mean there's not a pathology there or something that's fixable. Totally. So, you know, the pain issue, you should never hurt. Your gut should never really hurt. And we see your period should never be painful. Yeah. You know, that's treatable.

You don't have to fight through anything. And there's some people who are, I think this is actually a reason people don't come to their doctors. They're like, this should be a 10 out of 10 level. Like this should be a real big problem for me to seek medical help for it. And we're talking about abdominal pain. And that's not how I view abdominal pain, especially when we're talking about colorectal cancer, any amount of pain. that is causing you discomfort, that's new, that's weird, that's off for you. It doesn't have to be the kind of pain that sends you to the emergency room.

It just has to be different for you. It has to be weird for you and has to be bothering you. It doesn't have to be something that you're like, oh, but my, you know, my husband, with this kind of pain, he wouldn't go to the D-D. First of all, he would. Second of all, like, you shouldn't normalize. So pain, and when we're talking about, like, the kinds of pain that chloroical cancer causes, it is often not like this, like, life changing, like, I have a kidney stone level of pain.

It is subtle. It can just be, like, discomfort. Like, why is this there? So pain is a big one. Change in your bowel habits. That's a, what is that even mean? What is that even mean? Yeah.

This is any change in normal pattern for you. For some people, and we've seen a number of kind of big cases of celebrities who've had colorectal cancer now over the years, sometimes the only change they talk about is been something was just off. Like my stool was looser, for example. And like I thought maybe it was the coffee I was drinking. And then it turns out like it wasn't. You have to get in the.

habit of knowing what is normal for you. And so that means looking, right? And that means like looking every single day and knowing, okay, this is what my day to day looks like. And now this is what it looks like when I travel. This is what it looks like when I'm a little stressed. This is what it looks like when I start exercising. You have to know all of these different things and these patterns in your life so that when something changes and you're like, wait a minute, my diet hasn't changed. I'm still, my exercise routine is exactly the same. Why is this a little different? Just run it by your doctor. I tend to say have a low threshold to just put it on your doctor's radar. Send them a message. It's like the easiest thing. If you don't want to, if you can't

get an appointment, just say like, hey, I saw a little bit of blood in my stool. There's no doctor who's going to see that message and be like, okay, you're fine. Sounds good. Call me like in a couple months. Every doctor's going to be like, tell me more. You know, so just run these things by, and then the last thing is iron deficiency anemia. And this is a big one, especially for women. Iron deficiency anemia, officially you need a blood test to make that diagnosis, but you start to feel it often because you feel fatigued. You lose energy. And what's happening is that your body is losing iron, so you're not producing the red blood cells and the healthy, robust manner that you'd like to. And for women, a very common cause premenopausal is menstruation.

Yeah, yeah, yeah. And oftentimes if you have someone who has heavy periods, they're say, or even if you don't have any heavy periods, you might say. Yeah, women will be, they'll just assume it's her periods. And I tend to do that without thinking GI. Yes, it's common. And again, the most common cause of this is not colorectal. cancer. But because it's a kind of cancer that we often miss or we catch late, we can't keep brushing things aside without being more confident. And so if you're somebody who's been told,

okay, I have iron deficiency anemia, but I've been told by my doctor, it's my period, but I don't really have heavy periods. Or like, you know, I'm on like birth control. Like, this is odd. If it doesn't feel right to you, or you're taking iron pills, you're doing this, but your levels are not normalizing. That tells me we need to look elsewhere. And what could be happening is that you're losing microscopic, just small amounts of blood somewhere else. And or you're not absorbing iron correctly. And maybe that's a problem. Maybe you have celiac disease. Like there's other causes in the GI tract that can lead to this. So we need to investigate those. Now, along the same lines, talk to me about ferretin. Are you checking that with your patients? We do. We do. G.I.

checks like the full iron panel. We've started in our clinic. Yeah. Yeah, we do. And obviously, If ferritin is a number that can change depending on, you may have other diseases, if you have other kinds of things that might cause inflammation in your body, it can be falsely elevated. But we check a whole iron panel, which is just, you know, for anyone listening, it's like different measures of the different forms of iron that can take place in your blood. It can give us clues about the cause. But if you, the cause is that you're losing iron, you know, by the guidelines, by the American Gastroniological Association guidelines, men or women. If you have iron deficiency anemia

and we don't have a good answer for it, you have to get a colonoscopy. You have to get an upper endoscopy, actually, because I mentioned there's causes from H. Pylori, is a bacteria that lives there that can cause an acelic disease. You have to get both to make sure.

And I think we usually say, this is like our last resort. Like, let's make sure we like, you know, like try for years to fix their problems with their period. Let's not wait years before we look at like this other very common cause. Yeah.

Talk to me about color. Like, what does normal stool look like? And I've seen you discuss the color of your stool. Yeah. What does all of that mean? Yeah. Any shade of brown is normal. Okay.

Okay. That part won't surprise anyone, I hope. Are it green? Yeah. But, right, I get all these questions that are like, oh, I had like a weird green poop yesterday. Should I panic? And first of all, I'll just say, like, context really matters here.

So if you have a green poop and it's watery and you feel sick to your stomach and you have diarrhea, yeah, I'm worried about you. I'll tell you, like, let's get you some testing. Let's see what's going on. But if you have, like, one green poop, you otherwise kind of feel okay. I give people a pass a lot of times for weird colors. And that's simply because a lot of what we eat can show up in our poop. Like, people are taking these greens powders these days. That will give you a nice green poop from time to time. People, if you drink red wine, the anthocyan's in the wine. So we know this from berries, that can show up as a purple poop the next day. It can show up as a purple poop three days later, depending on how quickly your own body moves. And you may not be saying,

you might be like, well, last night I didn't have anything. It could be, think about like, you got to dig deep. Like, what did you have two nights ago? What did you have three nights ago? So I usually give a pass to anything that, you know, you otherwise feel okay if it's in like the greens category once. If it's like a pattern, I will say, let's have a look, let's get this test in. I never give people a pass for red. Red, maroon. black tarry stool, I'm telling you to go to the emergency room. Yeah. And maybe the only time I'll say, okay, okay, okay is if you were like, I had the biggest beet salad of my life last night, then I might like hold my own horses on it.

But otherwise, you have to make sure, again, that we're not missing something else. White poop, like clay, tan, beige-colored poop, that's weird. That's abnormal. That's a, so poop, remember, brown comes from Billy Rubin. we're producing that on our own. If we take that out, your poop is actually going to be this whitish pale color. So if you see that, it tells us that there's a blockade somewhere, that the billy movement is not making it into your gut. That can be a stone.

It could be a cancer. Like we have to check that out. That's an emergency. So I don't give a pass to that. I worry about black poop. I worry about red stool. And other than that, you can often attribute the problem to something that you've eaten. So a huge percentage of women will go through a phase of heavy menstrual bleeding to do with perimenopause because of the hormone fluctuations.

You know, they go through a workup. They end up getting put on iron, oral iron to help, you know, build, so they don't become anemic or fixing an anemia. Iron does a lot to our gut, too. Can you walk through some of the things to think about, walk about, you know, my patients are complaining of GI distress, constipation. Yeah. It does change the color of their stool. Yeah. What should someone know when they're starting iron?

Yes. One, you should know it will change the color of your stool for a lot of people. It'll turn it black. And sometimes this can be a really difficult conundrum in GI because we often put people on iron because we think they're having a GI bleed. And then they start having black stool. And then we don't know, is this the iron or is this the GI bleed? If you're just starting it and we're not worried about GI bleeding, just know you might see black. It can also slow down your gut.

So a lot of people get constipated when they have it when they start taking iron. And, you know, what I usually tell people, because they've looked into how iron gets absorbed, oftentimes people are taking, like, a pill once a day, like one, you know, one iron pill every day. You can actually take it every other day. I just saw that study. Yeah. Yeah. You can take it every day.

So listen, ladies, you don't have to take it every day. Yeah. You can skip a day. Skip that day. Take a day off. That'll actually help with the GI problems. And your body's going to actually absorb very similar amounts. It's not like you actually get more bang for your buck necessarily by taking it once a day.

Okay. Are there certain forms that you, what do you recommend? to your patients. Like, go take iron. Bye. Yeah, it depends. Like, so there's some people, like, so there's pill forms and there's also even, like, IV forms. Yeah. We'll talk about that. Do the pills first. Yeah, I mean, I usually recommend, like, ferrous gluconate. I don't necessarily have, like, a specific one that I think has been clearly shown to be better for the gut. As long as find the one that you'll actually take. Yeah. So I usually tell people to, you know, to take it every other day. That's more of my

recommendation. Yeah. That's great advice. Okay, talk to me about IV iron. Yeah. I've actually, I had really low ferritin and through minaraja. Yeah. Oh my gosh. And through peri menopause and went and had an iron transfusion. And it was life-changing. And I remember we would not recommend that unless we were pre-opping them for surgery and they had chronic, you know, low iron, we were going to get their fibroids out or whatever,

ion transfusion for pre-op a couple of weeks before to help them build up. Some of the pregnant patients who just, you know, we have a lot of PICA and a lot of nutritional issues in pregnant. and Ivy Iron was miraculous for these women, but I think it's so underutilized. Do you? Yeah, I think it's, I mean, I think, one, people feel amazing. Amazing. Right? Like, it's, like, very quickly. Yeah. And we have, we use it in GI often, probably not as much as we should, mainly because there is like this, like, you know, it is like this logistical hurdle. You have to deal with setting up an infusion center. Like, you have to come in, you have to sit down for, you know, two or three hours. Yeah. So it's, it's not as easy as popping a pill for sure. However, however,

I've seen cases where we do it because just the constitution is so bad and people are like, I'm over this. I just can't do this. They prefer the infusion. Great. I've seen cases where we sometimes have causes of GI bleeding that are like small blood vessel abnormalities that just trickle a little bit over time and we go in, we can't quite catch them. They just take iron from time to time to catch up and that's okay and we do it within an infusion. So there are a lot of like good reasons to get the infusion. It is underutilized. It's very safe. You know, like when I was in med school, you probably remember this. There was like some data were like, well, there's some slight increased risk of bacterial infections with iron infusions. And I think that

data is not as strong as we once thought it was and certainly not a reason to withhold this from anybody who needs it. I just want our listeners to understand they can ask for it. You know, especially if they're not tolerating oral iron. It's life-changing for some of our patients. And every, I mean, every GI Center has like a way of getting this set up. We just went, well, through the academic institution I was with, we just went to the Infusion Center, so it was me and all the chemo patients that day. Yeah. Yeah, exactly. Philly. Yeah. Let's talk about something we all wear every single day, the bra. Because I don't know about you, but I have reached a point where I am simply not interested in being uncomfortable for the sake of looking good.

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Bearminerals.com. Okay, early onset colorectal cancer. I see it a lot on social media. I see a lot in the news. What's going on? Yeah. This is one of the biggest. How early is early?

Yeah. And are we not screening appropriately? We are not. You know, early is defined, depending on the studies, either before the age of 50 or before the age of 45, right? We just changed the guidelines in the last couple of years. So now for someone of average risk, start screening at age 45. If you have a family is.

Screening meaning a colonoscopy. Yeah. Or are we doing this? You can get a stool kit. Or there's also these blood tests that just came online. And the thing that I would like die on this pill to just, if anyone could just listen to nothing else from this podcast, it would be this, which is that the reason colonoscopies are so important is not because they're a good screening tool. It's because colonoscopies prevent the cancer. So, you know, sometimes, yeah, we say like, yeah, there's all these different options to screen for colon cancer.

There are, there's only one option to prevent colon cancer, and that's the colonoscopy. And the colonoscopy, the think about what we're doing, we're going in there to look for polyps. Polyps are pre-cancerous. Tumors. There's small growths. Five to 10% of them, if we do nothing about them, we know we'll become a cancer. So it's not everyone, but it's five to 10%. We go in there in the colonoscopy.

It's a polypump. That's the point. We're looking for them. We see them. We take them right out. Like, will we see a cancer if it's there? Yes, for sure. You'll check the box that you got your screening.

But most importantly, we're going to take out those one or two. tiny polyps that we saw so you don't get the cancer later on in life. That's the measures. And that's why the colonoscopies have been shown to dramatically reduce the risk of mortality of death from colon cancer later in life, which is not what we can say about these other tests. What percentage of people are getting the screening necessary? Ah, so you asked, are we doing a good job screening? That's still a no. You know, it's, so unfortunately, you know, it's only, and the data changes, it's getting a little better every year, but it's somewhere in the like 60s to 70% range of the percent of people who are up to date with their colon cancer screening.

So one, no, we're not doing a great job doing the screening. I think there's a lot of misinformation about colonoscopies or fear apprehension, right? Everyone's like the prep, the prep is the worst thing. Let me be clear. Colonoscopy, the prep that your grandfather had, the prep that your dad had, it's very different now, right? Like, you don't have to drink this four liters of chalky liquid, which I've tried. It's not the best. I've done both.

Like my first colonoscopy was with the gallon, and then the second was just shoot the Shoot the pills. Like, you know, there's pills. There's even like a smaller volume. It was a small volume prep. Yeah. Yeah. I'm not going to say it's delightful. The end results the same. But remember, you want to be cleaned out. The point is to clean yourself out so we can find the tiny polyp. So that part doesn't change, but it's not miserable. And like I tell people, like there are lots of ways to make the prep taste just fine. Like shoot it back with a straw. Warm it up and put some ramen, like a ramen packet in there. Like you can get through that prep and you are buying yourself 10 years of time for the average risk. And you don't have to do this again. and you're giving your spouse, your family, the peace of mind that you've checked and prevented cancer. And when should anyone have an upper GI? Yeah, the upper GII, it depends. Like, there's some people who... So that's a scope going from the, from mouth throat, into the stomach. Yeah, we call it an upper endoscopy, an EGD, which stands for esophagosophagasy, gastrodoidoscopy, which nobody can say, so that's why we say upper GI or EGD. It depends. Like, if you have a family history of gastric cancer, stomach cancer. Yeah, I had it. Yeah, we want to take the both. So my brother

died of esophageal and my, lots of colon on my aunts and uncles. And so I, I was like, do both. Yeah. And once you do both. And I woke up and they're like, you're good. And I just like, what that did from my chronic quarters, all elevations. I mean, I think I lowered my risk of cancer just by knowing I'm okay. And I bet from your perspective, it was no different. Like you were asleep. You like, might as well get it done. I woke up. I'm like, we done? Yeah. Yes. In fact, that's what, I think there's so much fear about, like, is it going to hurt? Is it not? And most of the time, I would say, like, this is so common that patients wake up from their colonoscopy and they're like, when are we getting started?

And I'm like, congrats, we finished. It's already over. So, you know, so you should get the, there's certain conditions where you should get the upper endoscopy. Like if you have something called Barrett's, which can sometimes lead to cancer, you'll be getting regularly on the screen. If you have iron deficiency anemia, I come back to that. That's a reason to get the upper endoscopy. Because we're going to look for, like, is there something that's causing your astritis. Yeah, gastritis.

Something to be inflamed that we need to look for. But overall, they're easy tests for what they do for you, for what the years of life they could give you back. If you can't get a colonoscopy, though, for any reason, we should absolutely get you tested. Some test is better than no test. And so in that scenario, a stool kit where you poop in a box, you mail it right back, and you get the results within a week or two that says, you know, here's, yes, we detected something concerning or not. That's easy to do. Anyone can get it. And what is the blood test you talked about?

Blood test just came online. There were some big studies in the New England Journal of Medicine within the last couple of years. It basically showed there is a blood test we can do that's very, it's pretty good at saying yes or no, you, we see cancer or no cancer. It's not that good at saying yes or not preventative. Yeah, it doesn't detect those early growth. I mean, that's the whole problem with this tool kit too, is that it's okay. It's not great at detecting those early things. But there are a group of people who don't have a stable house or address that we could send a box to who are not that well-connected the healthcare system.

So if we catch them, you know, when they're coming in for another reason, like I would love to do this test. But what I'm describing is a pretty specific scenario. I don't think of the blood test as a shortcut for anyone.

Like, this is the quick thing. Let me do this. I'm sure our listeners are like, I want that blood test. Yeah, who would it, right? It saves, it's just a blood test. You might, you know, it'll be quick,

but what are you taking a shortcut on? You know, like, take a step back and think about that. Like, is this the area where I want to take the shortcut? No. I want you, if you're able to, to do the thing that's going to give you years of your life back potentially.

And that's, that is the colonoscopy. Okay, I love that. Yeah. Let's go back to irritable bowel. Yes. And why does it have a woman's name on it? You know, like. I know.

Like, if I went into AI and had, show me a picture of a woman with irritable bowel, I mean, it would be a shit show. Yeah. Literally. You know. I hate the name. I don't know, I don't, you know, the, like, the term irritable bowel, like, just the word for I was diagnosed with it in medical school.

I ended up having chronic active gastritis. Are you serious? Yeah. It's confusing because irritable bowel syndrome is this catch-all term for which we don't have a test, meaning by definition to become diagnosed with irritable bowel syndrome, all your tests have to be normal. And this has led to this big misunderstanding in medicine and for people alike, which is that, well, if all your tests are normal, then everything is normal. Then there's nothing wrong with you.

Then it's psychological. We were taught there's a huge psychological component. It wasn't biology, it was psychology. Okay, let me just, like, put it to you this way. Okay, so this is my specialty. I'm a neurogestontologist. So this is, like, all I study is, like, how the gut and the brain are connected. And there is a big psychological component to IBS, okay?

There's, like, a higher rate of anxiety and depression in IBS. But tell me one chronic medical condition that causes pain where there's not a higher rate of depression and anxiety, rheumatoid arthritis, right? And in an irritable bowel syndrome, we've done all of these studies, which are good studies, accurate, valid, that show people get better with cognitive behavioral therapy. They get better when they go on antidepressants. So do patients with inflammatory bowel disease. So do patients with rheumatoid arthritis. All of these conditions cause this cycle, this vicious cycle of pain to go back and forth. Because imagine you have IBS. Now what we know to be true, there's a lot of different causes of it. But one molecular pathway that's abnormal in IBS is that the sensory nerves in your colon, the trigger

or the threshold at which they are triggered is lower. When you have IBS, those nerves that are sending pain signals up to your brain, they're being triggered at the drop of a hat. If you have a normal amount of gas, which we all have, we have gas passing through our gut the whole time, that's going to cause those nerves to send a pain signal up to the brain. And it's not happening to your friend who doesn't have IBS. But that's not something you see with the naked eye.

You look at these two women, they look exactly. You look at this man and this woman. They would otherwise look the same. But imagine you're living your whole. day, your whole life, multiple times a minute, multiple times an hour, you're perceiving pain coming from your gut. Of course, you are going to become hypervigilant. Of course, you're going to become anxious about, can I eat this? Should I go out with my friends? Is this going to cause pain? Of course, you're worrying about it all the time because you're suffering. You're feeling

something. But then you meet your doctor who's like, okay, you're really anxious. I sense you're a little stressed. Why don't we work on that? And what they're missing is that, It's not the stress causing the symptoms. It's the symptoms causing the stress. Yes. Yeah. Okay. You teach that about 80% of Vegas nerve traffic runs from the gut to the brain.

Yes. What is that? Explain that to our poor little lay population who didn't go to medical school. Well, even for people who went to medical school, something that I bet nobody learned is that your gut is a brain. Like, this is the first. that people need to know and understand. I know. Right. Your gut's not just plumbing. And that's how I learned about it in medical school is that your gut is involved in digestion and it moves food from point A to point B. You suck out the nutrients and you just poop out the rest. Yes. Yes. It's just like this

passageway and all the other organs are doing the real work for your body. But actually, your gut, some people would say, I would say, it's the original brain. Like if you go back in time, evolutionarily speaking, there were many organisms, jellyfish, for example, do you see a brain? You see a brain in their heads? No, you can look through their little translucent heads. There's no central nervous system yet they're alive, yet they're making decisions. They're deciding, should I eat this, where should I swim? How are they doing that? It's because they have a brain in their gut. And that brain in their gut, we have today. It's called the enteric nervous system. It has like about 500 million nerve cells. That's more than the nerve cells in your whole spinal cord. And evolutionarily,

we have this very close connection between the gut, the brain in our gut and the brain in our heads that's unique. We don't have a brain in our hearts, not to hate on the cardiologist, but we don't have a brain in our lungs, the pulmonologists, but we have that in our guts. And there's a couple of ways that these two systems communicate with each other. One is they can kind of communicate through hormone signaling and through the bloodstream, but you have this very rugged fence around your brain and your head called the blood-brain barrier. So a lot of the signals from the gut can't reach the brain that way. They have to go through something called the vagus nerve. So the vagus nerve is this large cranial nerve, meaning it starts up in your head,

and it does actually extend down to almost every organ inside your body, but most strongly to your gut. And I think the thing that we didn't realize, for the last, like, honestly, century that we've been studying the gut brain connection, we've known about this since the 1800s, is that most of the signaling is going from the gut to your brain. We think that it's the brain calling all the shots, And that we used to think, yeah, it's stress that causes our stomachs to feel in well. Because we live that every day. Like if I'm nervous to have a chat with you on this podcast, maybe I'd feel butterflies in my stomach or maybe I'd suddenly have to go to the bathroom.

We feel that all the time. I had it last night. I mean, for the big idea. Yes. Because it was such a different audience for me. Yeah. And I was sitting there like massive gut pain. And I, like, the doctor in me is like, you're just anxious.

You're nervous. And the other part of me, are you okay? Are you going to be okay? Yeah. Yeah. Yeah. I ended up being okay. And then it went away.

As soon as the speech was over. Pretty much. Yeah. And that's, I think, how we've thought about the gut brain connection for so long is like these are all the ways that your stress, your anxiety can cause these changes because we feel that. But within the last 10, 20 years, we've found, wait a minute, most of the signaling is going in the other direction. It's from your gut upwards.

And that's really, that's what opened up our field of neuroGI is where we realize, wait a minute, this whole brain in our gut, it's producing neurotransmitters, just like the brain in our head. It's, but my specialty is dopamine. I studied dopamine signaling in the gut, which is how I ended up tying into Parkinson's. But it's producing the same neurotransmitters. It, too, can be the cause of anxiety and depression. And I think all of the changes that are happening in the gut happen kind of below our conscious perception most of the day.

So we don't appreciate how much of that signaling, because our brain simply cannot process all of that information consciously. But we are processing it subconsciously. That's called interoception. And so we're processing all those signals, and they're having a massive impact on our mood and on our health. But we just don't necessarily see it with our eyes and our ears. All right. Let's get to some – let's talk about fiber and gut health.

Oh, yeah. Let's talk about, like, how do we do this? Okay, so we know all the science, and we know it's all connected, and we know, you know, but what does it take to keep your gut healthy? If I'm going to – you know, how much fiber do we need? Yeah. Depends on what goal we're going for. Right. So let's start there.

Everyone needs to eat more fiber. We all nod and say yes. Yeah, yeah, yeah. And the last statistics I read, the average woman is getting 10 to 12 grams of fiber per day. Accurate. In her diet. Is that enough? Not at all.

Why not? Right. It's not at all. It's like that's like half the amount of fiber you need. So, okay, let's just talk about what fiber is and what fiber does, right? People I think often don't understand this about fiber. We don't eat fiber for ourselves. We don't possess the enzymes to break down fiber.

Fiber is not for you. Fibers for your microbes. And every day I ask myself, what have I fed about those microbes today, right? Because the microbes which live in our microbiome, we have now understood, it blows my mind that, you know, like how much we've learned in the last 20 years. But there is no organ in our body. There is no disease that cannot be linked ultimately in some way to what your microbes and your gut are doing. And so we have to treat them right. Fiber is their food, right? And again, fiber is not. just one thing. It's not like, you know, you just take like one fiber supplement for the day, you eat whatever you want and that's done. Your gut, in those bacteria, want a diversity of plant-based fibers because some, and they've done these studies, if you eat just like one type, then some bacteria who thrive on another kind of fiber, they're going to die off because they're not getting fed. And so you want to have one, you want to meet your fiber goals for women. That is 25 grams, if you're under 50, it's 21 if you're over 50. So if you're having just 10, grams a day. That's not enough. We need a lot more. But you also then, that's like,

well, honestly, that's like one, two, and three is meet your fiber goals. But for me, the second level is eat a diversity of plant-based fibers, right? And so it's not just eating the same old thing every single day, breakfast, lunch, and dinner, but it's trying to bring in lots of different sources. And then three, the third principle that I try to live by for my own gut is try to eat more probiotic foods, right? And this has kind of become a hot topic in the last year or two. people are really getting into eating more fermented foods like kimchi and sourcrow. Start somewhere. Like for a lot of times people are like, whoa, this is really intense. I'm not ready to eat kimchi, which I love, by the way. I put that like, it's so good with a little like chili flake. I love it.

But I started by just eating Greek yogurt. Like you can just eat Greek yogurt with live culture. So fermented foods, there's two things that can happen. One, fermented foods, the fermentation process changes the nature of the food itself. So sourdough bread, for example, is a kind of fermented food. and that's great. That'll do a certain amount for your gut bacteria. But then some fermented foods also have the live cultures in them, which means they're bringing other types of bacteria into your body that maybe are not already there or maybe that need a little bit of a boost.

That's where things like the Greek yogurt come in, kimchi tends to have a lot of this sauerkraut. The more of those that you incorporate into your diet, the better your bacteria are. So there was this big study from Stanford. It was a randomized control trial a couple of years ago. And basically they found that they looked at, people who are eating a high fiber diet. Wonderful. We love that. And then a second group that they

randomized to eating as many fermented foods as they could in a day. And these are Americans, okay? It's just like you and me who are like maybe not so like used to doing this. The people who ate the fermented foods, not only did they see this like bloom in diversity in their gut microbiome after like eight to 10 weeks, but they also saw 19 different inflammatory proteins in their blood went down. Went down. Yeah. Where do supplements? So fiber, let's talk about fiber. Yes. And talk about probiotics, because you said probiotic foods, and I think that was a very careful choice. Yes, yes, yes. Does supplementation have any role here? So personally, I supplement with fiber. I take cillium husk, like every day that I can't. And cillium, you know, has probably one of the

oldest and best studied fibers. It's a soluble fiber. And that soluble fiber is what makes it really special. The cardiologist got wind of the cillium before the gastroenterologist did. And so what they learned is that because it's soluble, it forms this gel. The gel. You have to drink it with water. Okay, remember this. Right? Because the whole point of it is that you want it to form this gel.

It needs water to do that. You don't want it to have just like a little bit of water and then just form this like thick compound. You want it to be like nice, easy flowing gel. So just drink it with like an eight glass, eight ounce glass of water. When it does that, first, it traps bile salts, which are these digestive salts that are inside your gut. That forces your liver to produce more because they've been trapped. So it lowers your cholesterol to do that. Great.

We and GI have then found that that gel, if you have loose stool, it can bind those loose pieces together and help you have more solid stool. If you have really rock, solid hard stool, that gel softens it out. So it's a shapeshifter. That's why sometimes people are like, wait, I have diarrhea, I have fecal incontinence. You're telling me to eat more fiber. That's just going to make me go more. That's going to worsen the problem. Not if it's sillium, not if it's soluble fiber.

That actually, you know, it can go in any direction it really works for you. So I take that every day. That doesn't mean that I don't think and believe that the best way to get fibers through your diet. And again, because Sillium is one type of fiber, I try to do that, but I'm also a realist. I know who I am. And I know that every day I don't quite meet those goals. I do probably most days, but not all. So this makes sure that even, like, definitely on days that I don't meet my goals, I have.

And then on the days that I'm meeting them, I just get like an A plus of my report card and I'm very happy. Probiotic supplements are way more murky. The data is not as solid as it has been for cillium. I think this comes as a surprise because probiotic supplements are often marketed as like, well, here's the one that gastronologists recommend everywhere, right? And the truth is the American gastronological association doesn't actually recommend probiotics for most conditions. There are some where the data is a little bit stronger, like in certain types of conditions in inflammatory bowel disease, we might. But the randomized controlled trial data tends to be all over the place.

So I don't recommend that off the bat. I do recommend probiotic foods just because we know that data is a little bit stronger and can bolster the gut. If you found a probiotic supplement that works for you and you're like, this changed my life, I never, I never rip it from anyone's hands by any means. But in my clinic, and this is my experience, more often people have come in saying, like, I've tried everything. I've tried all these supplements.

It's not working. What do I do? And then I say, okay, let's just, let's go back and look at diet. Let's go back to the basics. Let's go back to fiber for a second. Yeah. Is there, you know, a lot of people complain. They're like, I need fiber and they double their fiber overnight.

Oh my gosh, right. It's that, that, and then they come complaining. I always warn. Yeah. Because we do recommend some fiber supplementation if they can't meet their diet, but like to ease into it because the gut needs a minute. And because the bloating and the gas, talk about that. Yeah, it's so funny with like, you've seen fiber maxing, training on social media.

The number of people who have come to my clinic who have been like, I fiber maxed, I lived to regret it, like the next, you know, like several days had explosive diarrhea. That'll happen, right? And I think, and I love fiber maxing, like hashtag fiber maxing. I'm so glad that's trending. But I don't want people to have such a bad experience because they went from zero to 100 that they're like, I'm never going to do this fiber thing again. That's just not how you're supposed to fiber max, right?

It's like you said, you have to ramp up slowly because if you've been living with a microbiome that is not used to fiber, you can't suddenly be like, whoa, like over the system. If you're going to cause gas, you're going to cause bloating, you may well cause diarrhea. But not if you start low and go slow. So that's what I tell everybody ramping up their fiber. Like, we are all woefully under the goals, but that doesn't mean you should turn it over over now. Like we see this like every January 1st.

You know, like people like really try hard. So for example, if you're taking Sillium Huss, like you might, a teaspoon has four or five grams of it, I might say just start taking half a teaspoon for a week, for two weeks. See how you feel. Like let that subtle, let your body acclimate, then go up to another half teaspoon, right? And ultimately, you might want to get to a dose of two teaspoons per day. But start way, way lower than that. And even with dietary changes, which is ultimately the goal, you know, don't change all three meals of the day in one go. Like make one good, sustainable swap that you actually like.

Stick with that for a few days. Stick with it for a week. Try that out. And then, yeah, and then ramp up. Yes. So outside of probiotics and fiber, what else would you recommend for a gut healthy? Yeah. I mean, the biggest thing in 2026 is ultra-processed foods, right?

And so ultra-processed foods do two days. It's more than like adding things, which should we take out. Yeah, yeah. And I always focus on the adding, right? Because I think diet is, you know, as a gastroenterologist, diet is one of the hardest things about our lifestyle to change. And it's, it sometimes I think does people more benefit to say, why don't we add in an extra serving of vegetables at dinner than take away the thing that you love? I would rather have you do something where you're adding in something healthy than you take away something you love. And then you're like, well, I hate this.

I'm going to quit after two weeks. That's really hard. But, you know, sometimes, like, ultra-process foods, I don't think any of us can get rid of them 100% every day of our lives. That's the, like, unfortunate, sad world we live in. But I do think that there are small changes that you can make. Now, remember, ultra-process foods, they're doing two things for you that we don't want. One is what are they bringing into the table? They're bringing in these chemicals and emulsifiers, which we have studied in GI.

Some of these emulsifiers, one, they decrease the mucus barrier in the colon. That's your gut. You know, we've talked about a lot of the things your gut does. One of the big things it does is it protects you from the outside world. It's a barrier. Right. It keeps the bad stuff from getting across. Yes.

You want that to be really fortified. Those chemicals break it down. And they also change the bacteria. And they can cause inflammation, local inflammation. And so, one, they're bringing in new things that your gut doesn't like and doesn't thrive with. And it's not a surprise that irritable bowel symptoms are correlated closely in these studies to how much ultra-process foods you're eating.

But then, you know, sort of by definition in somebody who is the average American who we're eating about 60% of our diet from ultra-processed foods, it means that we're not getting fiber, right? Because the ultra-process foods tend to not have fiber. They tend to not have protein. They tend to have lots and lots of sugar, lots and lots of salt. You're actually, your microbes don't really love that much salt either. And that's a big problem with ultra-process food. So anywhere that you can cut those down. And again, don't go from zero to 100 because you can't sustain that. Like, fine. For me, I was reaching for chips and crackers as a snack, like from the a vending machine in my clinic. And I would eat those for snacks. And then finally when I made this swap, I was like, you know what, I'm just going to buy a bulk thing of cashews. I'm going to keep that in my office and that's all I'm going to eat. Like, then it became easy because it was the only option. I happened to love cashews.

But just like find that one thing for you that is actually sustainable. You're going to stick with it. And then build on that. Like, make one more sustainable swap every couple weeks. I ask all the academics who we interview. If I gave you a billion dollars for a study. Oh, my gosh. And I want you to focus on women.

because that's our audience. Yeah. Who else? What would you do? What would you study? I would try to study more on irritable bowel syndrome to start. And I would try to understand how we interrupt pain signaling in irritable bowel syndrome. We have made some progress.

We haven't made enough. In my field, you know, GI is 80% men. But meaning the people doing the work. Yeah. And they're great men. My dad's a gastronologist. He's wonderful, and there are a lot of really great men, but most of the GI, common GI conditions, like IBS, they're mostly women, you know, and I think to do the work, like, you need, we need to

just think a little bit more about the conditions that are affecting women. Women need to go into this a little bit. You know, we need to encourage more women to enter this field. And I think not enough people are studying pain signaling, because that's only one slice of GI, right? We have colorectal cancer to contend with. We have reflux to get that. We have so much pain singling disproportionately affects women. And that's the thing that I would want to study.

And the reason is that if we can study and we can nail down the mechanisms, then we can develop the right drugs for it. Right now, we don't have good drugs that treat pain in irritable bowel syndrome. We have some. And we do, and we have a lot of drugs that treat the contraception that treat the diarrhea. But the pain we don't treat well, or we have these sledgehammers. And I think it's because we haven't quite narrowed down the mechanisms and done the research. So anyway, that's a long answer. No, no, I love it.

I love it. Yeah. Because women spend 20% of their lives in poorer health. So if I had a male twin, if we had twins, a twin brother, you know, we would expect to spend 20% of our lives in poor health than they were. And half of that is in the last decade of life where we're seeing, you know, much higher nursing home. You know, we lose our independence earlier than in general. But back that up. The other is in reproductive.

years pain, PCO, PMOS, intubriosis, like, you know, things that autoimmune disease that are understudied. Yeah. And you feel like gut is a big part of that. Totally. Yeah. I mean, this is like the bluntest way to put it, but like think about the economic cost, like to how many days of work we miss because of our, whether it's endometriosis or more gynecological pain. But, but GI symptoms cause people to miss work, right? Like, especially with my IBS patients, people like, I just, I have to stay home today because I'm going to go to work and I'm going to be in the bathroom all day. And that takes a big toll. Like it changes your career advancement.

It changes what field you even decide to go into. And so your whole trajectory changes. And then like on top of the economic cost, like it's like the personal cause you're suffering. That's not something we want to pass on to the next generation. Let's talk about some dues and don'ts. Okay. I want to as we wrap this up. I want our listeners to leave with a checklist they can actually use.

So in your words, give me your top three dues for gut health. Number one is talk to. to your doctor about it. One out of three. Which, which doctor? Who? Yeah. Any doctor that will listen, but first of all, it'll be, it'll probably would start with your primary care doctor, but I also think that if you feel like you're not moving, like the wheels are just turning and you're not getting anywhere, ask for a referral for a gastroenterologist. But I do think, you know, like one out of three people don't bring up their bowel complaints to their doctor because they're so embarrassed by them. So like the one, like one rule I would tell people is don't be embarrassed. Like anyone who comes into my

clinic, I often see them like, you know, like hemming and hawing for the first five minutes. And I often just say, like, whatever you want to say, you're going to be the seventh person who's told me that same thing today. Like, just get it off your day. Don't feel embarrassed in front of a gastroenter neurologist. Like, we went into this field for a reason, you know, like, nobody forced us to do this. Like, we're here for you. So just to tell us, right?

That's the one thing. Two, I would say, this is especially important for women with IBS or otherwise. but if you have a doctor who doesn't believe your symptoms, you know, it's not your job to make them believe. It is your job to find another doctor. But so many, and this is not to, again, like, put the blame on women, but I think we feel that we have to make our doctors believe our pain. You know, like, we have to, like, a doctor should just, you tell them you're in pain.

That should be the end of that conversation. Like, that's how I think about pain. I'm not like, hey, but you look okay. You're not crying. You're not screaming. Hey, you're texting. You can't be in that much pain. That's not how I think about it. But you tell me it's 10 out of 10. That's what we're working with. And that's how I will treat you.

So your job is not to make them believe. Your job is to find a different doctor if that's the case. And then I guess the last thing is, you know, we didn't touch on this already, but I feel it's worth saying. If you have new bloating and your postmenopausal, don't brush that off ever. Get that checked out. Make sure we're not missing something serious like ovarian cancer. Yeah. The reason is that ovarian cancers, you know, we often see it sometimes.

We are terrible at picking it up early. We have no screening for it. Right. And it's usually heavily advanced by the time it's diagnosed. And the symptoms started years before. Usually with gastrointestinal symptoms. Yes. And it's vague.

Because like our ovaries, our uterus, our gut are not like in little walls. They are slipping and sliding all over each other all day long. Yeah. So including the bladder. It's like just a red flag for me. Not because I diagnose ovarian cancer every day, but if there's a postmenopausal woman who says, I have new bloating. I wake up with bloating.

That pattern really bothers me. I never let that go. I always double check. Okay. Now let's flip that over. What are your three top don'ts that people are kind of doing regularly and really shouldn't be for gut health?

Well, I think one is the ultra-processed food. We're eating more, like we know ultra-processed foods. I think we've known for a long time. They're not ideal for our heart health. They're not ideal for our metabolic health. I don't think most people, like, understand how much they are immediately damaged. the lining of the gut. Like the damage starts right then and there. So for your gut health,

ultra-processed foods are a problem. And of course they are linked. In fact, you know, we talked about early onset colorectal cancer. There is a huge body of literature that links ultra-processed food now to colorectal cancer. So that's like the one as much as you can. That's a big don't. Don't wait for symptoms to become a crisis. Like I think that's something I find myself telling men and women all the time is a little bit of blood bothers me. It doesn't have to fill up the Like any amount of discomfort bothers me. I want to hear about it. It doesn't have to be something that sends you to the ED.

So don't wait for it to be a crisis. And then last don't, don't put off your colon cancer screening. Yeah. You know, we put it off because it's inconvenient because we're like, this is going to be really, you know, bothersome. I wrote this story for the New York Times a couple of years ago about the prep for colonoscopies. And I was like trying to sort of explain how there are a lot of ways to make it easier. And one of the comments really stood out to me, and I'm going to paraphrase, but the, it was from a woman who read in and she was like, you know, like a lot of the comments were like, oh, the prep is so awful.

Like they, you know, like I was so, I didn't want to do it. And one of the comments said, you know, every one of these excuses was an excuse that my parent made. They put off doing the colonoscopy. And they died last year from colon cancer. and I regret every day that they didn't do it sooner. And that comment just lives in my brain because it's like, think about you're doing it for someone else. You're doing it for your family, for the people that love you, and you're doing it for yourself.

And it's not as bad as you think it is. Once it's over, you're going to be so glad you did it. What's the one takeaway message you want for our listeners? Well, okay, I say this is my soapbox, but I want people to start thinking about their gut as a brain and not as plumbing. And the reason that that's like, you don't have to dive into the science right there with me, you know, on every molecule. But if you just think about that as conceptually, it will change how you view your body

because you'll stop just treating your gut as a trash can. And you'll say, wait a minute, my gut is as precious as the brain in my head. Like if you were going to go for a bike ride, you'd wear a helmet, right? Like you treat that brain in your head, like the most important organ in your body. Well, so is your gut. And if you think about it that way, you respect it that way. it will totally change what you do to it. Do you think of our poop as a vital sign?

Yeah, totally. I mean, I look every day. I ask my patients to look every day because you learn so much about a person just by looking and not just looking, but being attuned to subtle changes. Thank you so much for coming on unpaused. We've covered so much.

Where can our listeners find you? Well, they can read my column in the Washington Post or they can find me on social media at Trisha Pastrita MD. Okay. Thank you so much. Thank you. You can watch full episodes of this podcast on YouTube at Dr. Mary Claire.

You can also find me on Instagram at Dr. Mary Claire and get honest and accurate information on health, fitness, and navigating midlife at the pauselife.com. Unpaused is presented by Odyssey in conjunction with good roommate media and longwave digital.