ZOE Science & Nutrition - Eat your way to better gynecological health | Dr. Jennifer Ashton & Prof. Sarah Berry

Episode Date: November 7, 2024

A good gynecologist is like a detective. She gathers evidence to diagnose infections. She uncovers the truth behind stages like puberty, pregnancy and perimenopause. Yet many women still feel that their physiology is a mystery.  What if a clue to that mystery hides in our diet? Similar to the gut, certain foods make the vaginal microbiome thrive. New research suggests that the right diet could alleviate symptoms of the most common gynecological diseases. Dr Jennifer Ashton is former Chief Medical Correspondent at ABC News and is a double-board certified OBGYN. She joins us today to discuss ‘nutritional gynecology’, a term she coined after realizing multiple women’s health issues have a direct relationship to nutrition. Alongside Jen is King’s College London professor and ZOE’s Chief Scientist Sarah Berry. Sarah shines light on the growing evidence of the role of nutrition in offsetting uncomfortable, and sometimes dangerous, symptoms of menopause. 🥑 Make smarter food choices. Become a member at zoe.com - 10% off with code PODCAST 🌱 Try our new plant based wholefood supplement - Daily 30+ *Naturally high in copper which contributes to normal energy yielding metabolism and the normal function of the immune system Follow ZOE on Instagram. Timecodes: 00:00 What you eat matters 02:00 Quickfire questions 04:05 What gets treated in gynecology? 07:19 What is the vaginal microbiome? 11:30 This affects the vaginal microbiome 13:46 The new field of nutritional gynecology 15:57 Does estrogen affect appetite? 17:19 The gut bacteria that breaks down estrogen 21:22 How food impacts puberty 23:21 Do glucose spikes affect pregnancy? 28:35 Symptoms of PCOS 33:00 Dr Jen explains endometriosis 37:20 Does diet affect these conditions? 42:00 How to test diet changes on yourself 📚Books by our ZOE Scientists The Food For Life Cookbook Every Body Should Know This by Dr Federica Amati Food For Life by Prof. Tim Spector Free resources from ZOE: Live Healthier: Top 10 Tips From ZOE Science & Nutrition  Gut Guide - For a Healthier Microbiome in Weeks Studies relevant to this episode Diet and Nutrition in Gynecological Disorders: A Focus on Clinical Studies (2021, published in Nutrients Effects of caloric intake timing on insulin resistance and hyperandrogenism in lean women with polycystic ovary syndrome (2013), published in Clinical Science Weight Regulation in Menopause (2022), published in Menopause Menopause, the gut microbiome, and weight gain: correlation or causation? (2020), published in Menopause Have feedback or a topic you'd like us to cover? Let us know here. Episode transcripts are available here.

Welcome to ZOE Science and Nutrition, where world-leading scientists explain how their research can improve your health. A good gynaecologist is like a detective. She investigates areas that women can't see on their own. She gathers evidence to diagnose infections. She uncovers the truth behind life stages like puberty, pregnancy, and perimenopause. Yet many women can still feel their physiology is a mystery. What if a clue lies in our diet? Just like in the gut, the vagina has a microbiome. And certain foods help these microbial communities thrive.

New research suggests that the right diet could alleviate symptoms of the most common gynecological diseases. Dr. Jen Ashton is a board certified gynecologist and a leading expert in women's health. As the chief medical correspondent for ABC, she's educated millions of people across America. And today, Jen will share a concept she's developed called nutritional gynecology.

Joining her is Dr. Sarah Berry, a professor of nutrition at King's College London and chief scientist at ZOE. Sarah's recent groundbreaking research examines the connection between nutrition and menopause symptoms. Jen, thank you for joining us today. Thank you for having me. I'm so excited to be here on Zoe. Well, we're excited to have you. And we have a tradition that always kicks off these podcasts, which I think you were being warned about earlier, where we have this quick fire round of questions.

They come from our listeners and we have these very strict rules. You can say yes or no, or if you absolutely have to, you can give us a one sentence answer. Are you willing to give it a go? I'm willing and ready. Great, so I'm going to kick off, Jen. Can certain foods reduce the symptoms of gynecological disease?

Yes. Does the vagina have its own microbiome? Yes. Can a poor diet increase your risk of infertility? Yes. Is weight gain in menopause inevitable? Yes. However, it can be modified and strategized. Can diet help with polycystic ovary syndrome? Absolutely yes. One final one, you get a whole sentence.

What's the biggest misconception about women's health? I think the biggest misconception is that women are smaller men, and that everything we know about men in medicine and science can be extrapolated to women, and that is not true, just as children are not small adults. I think that's fascinating, Jen. Now, you're a board-certified gynecologist and a leading expert in women's health,

and you've been researching solutions for common gynecological problems for decades. Now, there will be lots of men listening, but also women all over the world that have actually never even visited a gynecologist. So, can we start with the real basics, which is what is a gynecologist and what are the main health issues that you focus on? First of all, the definition of our specialty, obstetrics and gynecology, they're really

two different specialties, but they're combined in terms of medical education and training. It is considered a surgical subspecialty. I've been trained and have performed thousands of operations on women's gynecologic system, which means ovaries, fallopian tube, uterus, cervix, vagina, vulva. There's also a lot of medicine in gynecology. And so that would be reproductive endocrinology.

That would be some types of GYN cancers. Obviously the way hormones work from a gynecologic standpoint that affects puberty, pregnancy, and menopause, that's within the expertise of a gynecologist. Definitely in the United States, it is pretty standard for women to go to their gynecologist as their sole medical provider, whereas obviously in other parts of the world, there are a lot of other healthcare professionals

who can do a lot of the same things, but the training is fundamentally different. And what are the main conditions that you would focus on as a gynecologist? What I love about the specialty is, first of all, the age range, you know, we are literally seeing girls and women throughout their entire lifespan. We treat anything from painful periods,

polycystic ovarian syndrome, premenstrual syndrome, perimenopause and menopause symptoms. Oftentimes we'll manage osteopenia, osteoporosis as women get older, it's really the care of the entire woman. And I've said many, many times, I believe gynecologists should treat the whole woman, not just a body part.

So at least here in the United States, we tend to think of an OB-GYN as just vagina, cervix, uterus, ovaries, fallopian tube, menopause, but in reality, there's usually a woman attached to those body parts. So we're oftentimes seeing a lot of breast issues, even a lot of psychiatric issues as well, skin conditions, you name it. If it's happening to a woman, a gynecologist is oftentimes the doctor who's seeing it first. I think what you describe is very different to what I thought. I've never heard it described in a way that you do so holistically,

which I think is important because everything is connected to everything else in the body. I'm already taken away by how complex this is, like the way these things are fitting together, right? It's very hard. I wanted to switch us over to one of the other questions that came from the quick fire, because we already mentioned this thing, the vaginal microbiome, and a lot of listeners saying, what's that? I've never heard of it.

What is it? So most people now have heard of the term microbiome and that refers to the vast environment collection of bacteria or organisms that live in our body all the time. The gut microbiome, for example, has more genetic material in it than our actual DNA. So we're actually more bacterial species than we are human species, which I think is kind of interesting to think about. And even though the gut microbiome is still relatively in its infancy, meaning like 10 years, 15 years of data,

not a hundred years of research, not 100 years of research. It's now a really exciting time specifically for women's health because we're learning that it's not just about the bacterial species in our GI tract, but there's also bacteria in the vagina, right? The vagina is an open conduit from the outside world to our peritoneal cavity through the uterus. The uterus is kind of like the intermediary room. And so there are bacteria in there.

There's also fungal species in the vagina oftentimes. Of course, viruses can live in the vagina as well, but specifically talking about bacteria in the vagina, they exist in a nice, peaceful symbiosis. There's a lot of different species of bacteria in the vagina, and when they are getting along with each other, the woman has no symptoms. What about when they're not getting along with each other? When they're fighting, then the woman can have symptoms. What about when they're not getting along with each other? When they're fighting, then the woman can have symptoms. And what can those symptoms look like and feel like or smell like? There can be itching, there can be discharge, excessive amount of discharge, there can be an

odor, there can be painful intercourse. And in some cases, potentially even that bacteria can go upwards, can ascend through the cervix, which is kind of the gatekeeper to the uterus and cause an infection in the uterus or beyond. Thankfully, that rarely happens. But just in terms of day-to-day existence for the woman, we probably all have friends. I've seen many patients through the course

of my nearly 20 years in practice, where it's almost like a binary population. There are women who say, I've never in my life had a yeast infection. I've never in my life had any kind of vaginitis or vaginal infection. And then there are women who say, I am so prone or vaginal infection. And then there are women who say, I am so prone to vaginal infections.

I've had bacterial vaginosis, I've had yeast infections. You know, I get a yeast infection around the time of my period. And there are a group of women, of course, who fall in between that, who maybe have one or two over the course of their lifetime. But it's more common in my, again, my clinical experience that it's one or the other.

And so the vaginal microbiome now is a really hot area of research, which I think is fantastic. And what kind of things can affect it for the negative or for the better. We discussed the gut microbiome often on this podcast. You know, my co-founder, Professor Tim Scripp, this is like his area of specialization.

Sarah spends a lot of time as well. We haven't really talked about the vaginal microbiome at all. Is it playing some sort of beneficial role in the way that we now understand the microbiome does in the guts, or is it just that because it's open, of course there are some bacteria? Like, do we know any of these things today?

I mean, if the gut microbiome is overall big picture in its infancy, the vaginal microbiome is even more, it's a newborn. There is some really interesting preliminary data that suggests that what we eat absolutely has an impact on the vaginal microbiome, which is interesting, but our behaviors also have an impact on the vaginal microbiome. Semen changes the pH of the vagina.

Menstrual blood changes the pH of vagina. Condoms and certain lubricants change the pH of, saliva changes the pH of the vagina. Condoms and certain lubricants change the pH of, saliva changes the pH of the vagina. So all of these things are constantly affecting the species of bacteria, some of which are doing good work. And so we want to make sure in general that we're learning as much as we can about ways to help

it and ways to avoid hurting it. I don't think there's enough of a body of evidence right now to make broad sweeping statements yet, but there are a lot of researchers doing really interesting work on this, particularly in the area of supplementation and diet and how that can potentially impact the vaginal microbiome and therefore the clinical well-being of a woman. We study, like Jonathan said, loads about how food impacts your gut microbiome. And for me, that is obviously it's logical, the food's actually all, or you've got the debris of the food getting to your gut. So you've got the food for the microbiome and the bugs that are down there to feed on.

So you've got the food for the microbiome and the bugs that are down there to feed on. I can't quite understand how food can impact your vaginal microbiome. And I know you've coined this term in nutritional gynecology. Could you just expand a little bit on that? Well, first of all, you're thinking about it the right way. And I don't think that anyone at least, and definitely myself included yet, can say with the utmost scientific certainty and that something conclusively does X, Y or Z. Again, the first step as you know,

as a scientist is observation. And then we start the exploration and experimentation. And because there's a different woman attached to each vagina, it's very difficult to tease out these variables. But you ask about an area that I find incredibly fascinating. I started describing it as nutritional gynecology. What does that mean? It means how the area of nutritional science,

but practically how we eat, how it affects the gynecologic realm and wellbeing of a woman. And if you think about big picture and go back to my answer to Jonathan's first question and your first question of what is gynecology, and we talk about puberty, we talk about pregnancy, we talk about PCOS, we talk about perimenopause. Most of them, by the way, all start with P. I'm not sure why. And they're all influenced by the food that we eat. They all have a major role for food, nutrition, and metabolism, right?

When you think about it. What happens in puberty? You don't menstruate, you don't get your first period until you have a sufficient amount of body fat tissue, which also is a source of estrogen. Right? And so there's weight gain that comes around that time that's important for puberty, that's important for the first period, that happens then. Pregnancy, we don't need to remind people

what happened in terms of pregnancy, metabolism, weight, and its hormonal interaction. PCOS, that overlap between, in some cases, insulin resistance, weight gain, difficulty losing weight, and increased risk of going on to develop type two diabetes. There's a hormonal and metabolic component to that and so too perimenopause and menopause.

So we know that estrogen, for example, estradiol, many even gynecologists may not realize this. Not only does it affect every kind of organ system in the body, but there in the central nervous system, estrogen acts as an appetite suppressant. Interesting. So when a woman goes through perimenopause and menopause and her estrogen levels start to decline, it's one of the reasons to go back to your rapid fire question, Jonathan, that perimenopausal or menopausal weight gain is really inevitable.

That doesn't mean we can't over-strategize it, but estrogen level drops, you get less central nervous system appetite suppression, you get more insulin resistance with less estrogen, and you get an increase in weight gain in adipose tissue and in particular, visceral adipose tissue. And I think that's a really important point because I think that it's such a challenging time anyway, perimenopause and menopause.

And if you think, my gosh, what's wrong with me? Why am I failing? Why is my body changing? And I think to be aware, and we see this in our own ZOE data that we have on all of the research we're doing on menopause, that there's three things happening. There's the changes in hunger. You're not perceiving hunger in the way that you used to. So we'll often hear women anecdotally say, but I'm eating the same, but I'm feeling more hungry. Yes, that's because we know estrogen affects your hunger signaling. We know that estrogen affects your metabolism.

So we know again from our own research and what else has been published, that the way you metabolize food changes. And then exactly in the way that you said it also changes where you distribute the fat and how much fat you lay down and you lay it down in your tummy, which is metabolically worse for you, et cetera. So it's also about being kind to yourself as well. Yep. You nailed it. So it's also about being kind to yourself as well. Yep, you nailed it. And there's even more factors.

We were just talking about the microbiome in the gut and the microbiome in the vagina. There's an astrobalone in the gut, which are bacterial and fungal species that can break down and metabolize estrogen and other hormones. And depending on largely your diet, but of course also your genetics and a number of other factors, you can either break down more estrogen and then you're basically in effect contributing

to low estrogen symptoms, or you could be eating a diet that positively affects these bacterial species and enables them to either not break down as much of the estrogen you have or to recirculate it back into your systemic circulation. So that estrobalome is a newish term that a lot of people who do this kind of research are paying more attention to. And I think that's why, again, it's important to understand that women are different than

men in what's going on in their gut, just like in the rest of their body, but women of different ages are also experiencing different metabolic and bacterial behavior that affects the whole organism. I think it's pretty amazing. and bacterial behavior that affects the whole organism. I think it's pretty amazing. Could you talk about how diet maybe hits then puberty, for example, and what the difference is? What's the consequence, I guess,

of like poor diet on puberty? So I think, first of all, in the United States, and there's a general consensus, because there's an acronym for it, SAD, the Standard American Diet. And it's not just sad, it's bad. It's heavily processed or ultra processed foods that are typically calorie dense, nutrient nutrient poor and actually result in sending signals from the gut to the brain that then send signals back through the rest of our body and drive us to seek these foods that

are not healthy more. And they have a direct effect on weight gain and the whole domino effect that follows from that. We know we're seeing the consequence of this, that in part, childhood conditions of overweight and obesity are leading to girls having their first period at an early age. It's one of the factors. It's not the only factor, of course. So Jen, you're saying that the food that they're eating is actually causing them to go into puberty earlier than otherwise?

I would say indirectly, I'm sure there are people who would say directly, yes. Again, it's one factor. Their genetics are another factor, exposure to other environmental agents like the Forever Chemicals, which has known to be endocrine disruptors, plays a role. But our bodies, when you talk about women and girls, are so finely attuned to fat composition and body weight that it's a big, big factor. And Jen, given that for adolescents, they have the highest intake of ultra processed food,

this is in the UK and the US. What is this doing to girls who are going through puberty? What are the harms of this? And what can we do positively for this? Well, this is why I love this concept of nutritional gynecology, because it really involves one hand talking to the other and one area of science,

literally hybridizing a base of knowledge and taking things that were traditionally siloed, like just talking about food and saying, how does this food and this way of eating and the conditions of overweight and obesity affect, in this case, in my field, gynecology? And when you talk about that and you look at puberty, you say, what are the risks or consequences

of a girl going into puberty, being overweight, being obese? Well, based on association and observation, a higher chance of that girl having polycystic ovarian syndrome or PCOS, a higher chance of that girl when she gets pregnant having gestational diabetes or other complications of pregnancy that are directly related to her weight. And then when that girl becomes a perimenopausal woman, difference in vasomotor symptoms, an earlier menopause, a later menopause, a more severe menopause. So we really have to start connecting the dots more with what we're eating, our nutritional

status, the impact that has on our health and all of these reproductive hormonal stages. And so you touched on puberty. I want to move on to the next P, which is pregnancy. Well, listen, you're growing a human, right? And so there is no question, there should be no question that the nutritional input and the metabolic factors that go on during pregnancy are important. I was fascinated by the nutritional input and the metabolic factors that go on during pregnancy are important. I was fascinated by the nutritional input.

And when I went back to Columbia University and got my master's of science in nutrition, I remember the day I sat in a lecture given by a very famous sugar researcher in the United States with a PhD named Nicole Avina. And she was talking about the importance sugar researcher in the United States with a PhD named Nicole Avina. And she was talking about the importance of the in utero environment for the offspring and the generations from that offspring.

And based on animal data and human data, whereby the glucose concentration of amniotic fluid has a role of genetic imprinting on that fetus. You have a pregnant woman, and I'm going to overgeneralize this to make the example very, very clear. You have a pregnant woman who consumes a high sugar diet, sugar sweetened beverages, ultra processed foods. She takes in a lot of sugar in her diet and beverages. And that from a couple of quick steps results in an amniotic fluid concentration with higher glucose that surrounds the fetus. That fetus is exposed to this high glucose blood flow

from the mother and the placenta. And that in turn winds up producing a high glucose level amniotic fluid, right? And that's the fetal environment. That's the in utero environment. Because of the mother's diet, the fetus is exposed to this high glucose. And that has what, again, goes through this concept of genetic imprinting, where that fetus then has an increased risk of obesity, type two diabetes, metabolic syndrome. And so truly, as a woman and a mother, as well as an OB-GYN, when I learned this 10 years ago,

I thought, oh, fantastic, another reason that I can feel guilty what I did or didn't do when I was pregnant. But we're not talking about blaming, we're not talking about pointing fingers, we're just citing the fact that the in utero environment has profound metabolic consequences that could affect that fetus way down the road

and therefore that fetus' offspring. Jen, we are spending a lot of time as nutritional scientists looking at this now that we're understanding just how important maternal diet is to the offspring. Isn't it incredible, right? And to future generations. And so I think it's important to say as well as incredible, right? And to future generations. Right. And so I think it's important to say, as well as sugar, it's everything that the woman does. That's right.

Whether it's how stressed you are, that's your physical activity, but it's your entirety of your diet that we now know is incredibly important in shaping the health outcomes for your baby in the future. Correct. And I think that, again, it's one thing to talk about the science and the biochemistry. It's another thing to talk about the person and the patient and the real human being. You know, pregnancy is an incredible process

and women are incredibly resilient. We all know, we really know intuitively as well as intellectually, what's good fuel for our body and our growing fetus and what isn't. Yes, we have to live with moderation. Yes, we have to be realistic as well as idealistic. But I think that most women will know that having an occasional cookie or slice of cake or cupcake is very different than having one every single day, especially when you're growing another human. What my mother, who was a registered nurse, said to me, both as a mother and as a nurse, control the controllables.

So there's so much that's not under our control, but there's a lot that is. And so to the extent that we can control something, which when you're talking about 40 weeks or nine months, that's not forever. It's a little easier to do that. Can I ask one quick question before we move off pregnancy? Because you talked a lot about after being pregnant. What's the evidence about diet affecting your ability to get pregnant?

Because I've heard a lot about that. What does the science say? I think that the science there is a little bit more vague. So there's no evidence that any one food or any one supplement in isolation has any statistically significant impact positively on a woman's fertility. But again, as an organism,

we know things that are not good for fertility, which is a lot of inflammation, excessive body weight or hormonal imbalances. And those things obviously can be tied to diet. What I encourage women and couples who are trying to conceive is try to eat from the farm, not the factory. Try to minimize your ultra-processed or highly processed foods.

Obviously don't smoke, don't consume alcohol. Again, that's not good for your whole body, not just your ovaries or your fallopian tubes. And again, in that way, to use Sarah's term, I really do take a holistic view. Can we move back to talk about PCOS? Yes. Are there particular conditions that are more common for you to treat in an individual? PCOS, polycystic ovarian syndrome, it's called the most common but least well understood hormonal condition affecting women.

And in the medical literature, it is quoted as affecting 10%, sometimes 15% of women. I believe it could be even higher than that. So it's incredibly common. Hallmark features are signs of hyperandrogenism. Signs are increased testosterone levels, producing acne, excessive body hair, male pattern baldness, difficulty losing weight or gaining weight, menstrual irregularities, so irregular periods.

Those are a lot of the common signs or symptoms, but just to keep it fun and interesting, women can have PCOS and not have any of those signs or symptoms at all. As a woman listening to this, I think a lot of women will think, well, Holden, I might have one of those symptoms, which doesn't necessarily mean they've got PCOS. Unless you have one of those kinds of symptoms and it's bothering you or impacting your life,

is it something that if you didn't get it investigated, there would be no long-term harm? Well, the thing that's interesting about PCOS is that women and girls with known PCOS have a higher risk of going on to develop type two diabetes in their lifetime. So it's certainly not a scenario where we recommend screening every woman

or every girl for this. But because of the constellation of symptoms and signs that we talked about, if they're persistent, if they're new, if they're bothersome, absolutely a workup, you know, an investigation should be done to see if that person has it.

And I'll give you a couple of examples. Acne on the back or chest of a woman or an older adolescent or teenager is not common. And if it's persistent, it is generally a sign of PCOS. All of us can get a pimple on our face every once in a while, but extreme or even moderate to extreme acne on the back or chest of a woman, it is generally a sign of an androgen imbalance.

So a higher level of testosterone. And the clue both for a dermatologist really a sign of an androgen imbalance. So a higher level of testosterone. And the clue, both for a dermatologist as well as a gynecologist will be when a dermatologist can't really have an impact on acne, I usually say, and most of them would agree that that's because it's not a skin problem, it's a hormonal problem.

And so all dermatologists are very accustomed to hormonal basis for acne. They see it all the time. And so their radar, their index of suspicion is generally up already. Maybe this isn't a skin problem, maybe this is PCOS. I'd love to know about the relationship between diet and PCOS.

There's been actually a decent amount of this reported in the peer-reviewed medical literature. Not enough, in my opinion, never enough, but there's been a decent amount of, you know, well-constructed studies that, even though many of them are observational, it's still some valuable information that suggests that women with PCOS who lose

5% of their starting body weight, and so most of that is going to be fat tissue, fat mass, can have a significant impact on their ovarian function, their ability to resume regular ovulation if that's a problem for them, and improve their insulin resistance. That's good because it's very, I think, empowering from a behavioral and nutritional standpoint. What's not so good is that it's easier said than done. If you talk about a woman who weighs 200 pounds

or what is that, about 90 kilos, right, 85 kilos, you know, 5% is 10 pounds of weight or 5 kilos. That's hard. And given how hard it is, is there any dietary changes independent to weight loss or in addition to when women are trying to lose weight? It's a great question. And I think the general approach has been a diet that is certainly lower in added sugar.

And I really go by the max added sugar of no more than 25 grams a day, which is the World Health Organization recommendation for women. You'll hear people say for PCOS, low carb, but remember our bodies run on carbohydrates. That's what every cell needs to function is glucose. So not all carbs are created equally, right? So eating an apple is very different than eating a cookie when you're talking about metabolically

and hormonally and PCOS for everyone. By the way, I would say that for men as well. Eating an apple is very different than eating a cookie when you're talking about metabolically and hormonally and PCOS for everyone. By the way, I would say that for men as well. Okay? So for people with PCOS who are incredibly sensitive to how their body metabolizes carbohydrates, a diet that's higher in lean protein, even plant-based protein, higher in the healthy fats, like the olive oil, the avocado, the nuts, is going to be helpful. It's not going to be a magic bullet,

but it should be the mainstay of how someone with PCOS eats. But guess what? It should be really the mainstay of how we all eat. Yeah, I was just thinking that it's the mainstay of the ZOE diet that we encourage as well, with a lot of fiber as well. Cause I think it's really important if anyone's ever going onto a light low carbohydrate diet to make sure they're still getting enough fiber.

Totally. That's key. Okay. So we've talked about the four P's. So puberty, we talked about pregnancy, we've talked about perimenopause and we talked about PCRS. There's another gynecological condition that I hear about a lot that I know affects about 10% of women and this is endometriosis.

And it's something certainly I don't understand. I know lots of my friends talk about it that they might have it is incredibly underdiagnosed as well. Could you just walk us through that quite briefly and how diet might be able to help? Let's talk about first of all, what endometriosis is. It comes from the term endometrium, which is the inner lining, the type of cells that are inside the uterus. And in endometriosis,

there are a lot of different theories as to why this happens. But in endometriosis, those endometrial cells are dispersed outside the uterine cavity, basically anywhere else. So they can implant on the sidewalls of your body. They can implant on the bladder, the bowel, the undersurface of the diaphragm. There have been women with endometriotic implants in their lungs. So it can be an incredibly painful and debilitating condition that is chronic. As you mentioned, Sarah, it is underdiagnosed because typically it's a diagnosis that has to be made surgically most of the time, not all of the time. There's some very exciting research, by the way, about ways to test for endometriosis using menstrual blood, which I think is maybe interesting

down the road, some other ways to test for it, but we're not there yet in terms of gold standard of testing or screening. So how could someone listen to this at home who has some concerns around this, how would they be able to identify it? Pain is the hallmark symptom of endometriosis. It's the most common and it's the most severe. Low pelvic pain that is generally, but not always, cyclic. So again, remember these endometrial glands, they're hormonally responsive.

So just as the uterus lining sheds with a woman's menstrual cycle and change in her hormone levels, you can imagine that contraction of the uterus causing menstrual cramps occurring in microscopic areas all over the internal cavity where those endometrial glands are kind of splayed out. So it's very painful.

Refractory pain or severe pain is a hallmark feature of endometriosis. There's a saying in gynecology that is still, I believe, valid, but it's not 100% that a teenager, so an adolescent who has been put on non-steroidal anti-inflammatory medication, so that's something like ibuprofen available all over the world, and low-dose birth control pills, those two treatments together, who still has severe pain with her periods, have a 50% chance of

having endometriosis. So that could be a clue. And I believe for a woman of any age, so, and even an older woman, 20s, 30s, 40s, if you're on birth control pills for whatever reason and you're taking a drug like ibuprofen for pain and you still have pain, that's a red flag. And there's things that you can do about it if you make it to a gynecologist? Yes, there are ways to manage it. There's not a cure for it and it can be very difficult.

The treatment should be individualized and it really, really is important, ideally, if possible, for a woman who thinks she has endometriosis or knows she has endometriosis to go to a gynecologist who really has a tremendous amount of experience in managing it because it's not a one size fits all treatment. I mean, one of my takeaways from this is just how complex a lot of these female hormonal related things are, Jen, just listening to this, that there's, you know, it's a bit like when you talk about, Sarah, about going through menopause and the way that like every cell in your body is changing with these hormones. I'd love to switch to actionable advice. And what does a diet look like that supports

overall gynecological health? I think it looks exactly the same as the diet that supports brain health and heart health and skin health, you know, head to toe. I think the importance in considering the term of nutritional gynecology is just so that we have an awareness that yes, how we eat affects all of those peas and more, right, as women, but that doesn't mean that we should eat one thing for our ovaries and another thing for our brain. So what that diet looks like is a diet that has a lot of fiber, has not a lot of added sugar, not a lot of chemicals, that is as much as possible comes from real, whole, or fresh foods that resemble their form found

in nature, and that we minimize, again, as much as possible chemical additives. I think in a lot of ways, even though people try to make it very complicated, it's actually not. It's very simple, but that doesn't always mean it's easy. I love the fact that you've said that actually what we need to eat for good gynecological health is what we need to eat for good heart health, for good brain health, for our whole body health. Because I think there's so much misinformation out there.

And I also think there's lots of companies that are preying on people's desperation, whether it's fertility, whether it's menopause, whether it's other gynecological areas. And I think the principles that you've referred to are the principles that good nutrition scientists would promote to everyone. They're the principles that underpin all of what the findings are that we have at ZOE and the advice that we give to our ZOE members. So the fiber, the diversity as well is something that, we really promote having these diverse,

whole plant, unprocessed foods because we know that they positively impact the microbiome. And I think this is really interesting that there might also be positively impacting the vaginal microbiome that there might have beneficial effects as well. Yeah, and I think it's how all of these things interact with not only each other, but with our organism,

our entire body, that's the secret sauce. And so they all need to be good. Another way of looking at this a little bit outside of the realm of nutrition, but definitely connected is that the best diet, the best, most pristine, perfect diet is still not enough to negate a bad lifestyle. So you can eat perfectly, but if you don't sleep enough and if you pollute your body with smoking or vaping or too much alcohol or

in some cases any alcohol or you don't exercise, it doesn't matter how great your diet is, you're not going to be a healthy organism and I think that's the balance that's really really important. Now we often talk about the four pillars of health. Diet is one of them, obviously we believe it's one of the most important, but also physical activity, stress, so mental health, and sleep being so, so important. Yeah. So I think that there is emerging data for a variety of gynecologic conditions that high

fiber is beneficial, whether you're talking about pregnancy, PCOS, or menopause. I think we can all agree with that, but high fiber is good for literally almost everything, especially the gut microbiome. A lot of the regular listeners to this podcast will also be Zoey members, which means they're part of this personalized nutrition program. Then after you go through this program,

you retest again about four or five months later. One of the specific things we see is that people who are eating a high diversity of plants, and the number we often talk about is 30 plants a week, have better microbiomes, and they tend to have a better starting point of their health. And also if they make that change, they have like a better starting,

like end point of their health. None of that has been focused on anything to do with gynecology specifically. As you hear that, are you surprised and how might that link through to someone who's maybe thinking about any of the many conditions that you were talking about today? I always encourage people all the time,

you should do an experiment in self. You should be perpetually and constantly curious about you. In science, we say N of one. Well, you're the one. You're really the only subject that should matter to you. So when you add those 30 plants a week and you get a test that says, yes, you have changed your microbiome, then the real fun starts because then you should be looking at literally everything about yourself

as your own little living science experiment and say, what do I notice? Is my skin clearer? Is it more, does it look more hydrated? Am I sleeping better? Do I feel more cognitively sharp, more physically energetic? Are my bowel movements better? Is my sex life better?

Do I have more vaginal lubrication? Are my periods less painful? I mean, just keep going down the list. That's the exciting thing about science, and you don't have to be a scientist to do this, right? You can use yourself as your own running science experiment. But what you care about, because you've done incredible science and research

and you have the data, is that a Zoey listener can say, well, I did this and this is what I feel, right? And that doesn't mean that if they don't feel anything that it's not worth doing, by the way. And I want to make that very, very clear because that's a conversation or an example, an analogy that you could make for someone who drinks social alcohol, right?

Or moderately, you know, and says, well, I did a dry month, which I know is very popular in the US. I do several every year. I know it's popular in the UK and other parts of the world. And they say, yeah, I did it. I didn't really feel any difference. But that doesn't mean they didn't do something good for their body by doing it. So it's just another endpoint. It's just another thing that I would encourage and I'm sure you would encourage your listeners to do. It's part of that experiment itself.

Yeah, I mean, obviously as scientists we want to show that the average response improves. We recognize that we're all hugely variable. This is the whole purpose that underpins what we're doing at ZOE, is understanding what's the best diet, what's the best food for each individual. We have though been really interested in looking at how this plant diversity beneficially changes the microbe, but how it has the impact on all of these different things you've described. And what we see is that if you have a more diverse plant-based diet, you're giving yourself loads of different fibers. We need a diversity of different fibers.

You're giving yourself a diversity of other chemicals. We know on average each food contains about 72,000 chemicals. We want to have a mix of all of those thousands of chemicals. And some of these chemicals like polyphenols have such a profound impact on our gut microbiome and on our health. And it's only though by getting a diversity of different plant-based foods,

so up to 30, maybe even beyond that, that you're going to have this really big impact, we think, on your health that we know is partly mediated by the microbiome. And there's a precedent for that also in the rest of our health and physiology, which is in the world of exercise physiology. You talk about the four pillars, and I talk about them too.

I really believe they are all equally important, believe it or not. Some have much more research and data behind them than others, but your body is a very smart machine, just like your gut microbiome is very smart. And it will get used to anything that it sees too much of, including exercise, which is a good thing. So I love the concept of diversity and what you eat.

It's no shock to me, you know, it was no shock to me even before I got my master's in nutrition that that's better for our gut microbiome. Just like someone who tells me, I run, oh, I exercise. I run five miles a day. And I say to them, that's first of all, impressive and great and good for you. And it's better than nothing,

but understand that your body sees five miles a day as a flat line and you need to challenge it. You need to confuse it. You need to mix it up a little bit. Jen, you talked about having almost the proof in the pudding, as we would say in England, that it's all very well that you see a change in the gut microbiome from adding in plant diversity, but does it change how you feel?

What we found is that people who have a greater plant diversity, they actually feel better. We've shown this in a randomized control trial that we've very recently published that was involved feeding people a new product that we have. It's this whole food supplement called Daily 30. And I'm not saying this as an advertisement to the product. I'm saying this as it being really good evidence for why we know that plant diversity does actually impact how you feel and not just your microbiome. And we ask people to either eat the Daily 30, which is giving them a diversity of plant-based whole foods with loads of different fibers, polyphenols, for a six-week period. Or they had a probiotic capsule, or they had

a functional equivalent, which is what we use in nutrition as a way of measuring if you were to place one thing with the other. And this was kind of ground-up croutons. And what we found was those individuals who were eating the Daily 30 every day for six weeks, they had a significant improvement in their gut microbe. They had an improvement in species that we know associated with less inflammation, lower blood pressure, lower blood cholesterol, et cetera. But these people felt better. They had better mood.

They had better energy. They had less hunger. They had more alertness. And I think that's incredible because I think that we don't ask that enough when we're thinking as scientists and to see it play out, not only as an improvement in the gut micro bone, but in how people felt, I think was really, really valuable. And it speaks to the impact that your diet can have on you from a clinical level and a cellular level to a systemic level, which I think is really, really

important. And it's not a surprise, right? I mean, if you change someone's diet for the better, the vast majority of people will feel better because that is how food can be our medicine or our poison. Are there other lifestyle changes other than diet that can really support their gynecological health? I actually believe that meditation and stress reduction talk about something that hasn't been studied. I think, I believe there is very likely a connection between meditation and stress, overall stress,

we're talking about negative stress, non-positive stress, and someone's gynecologic health because of the hormonal interaction there. The brain sends hormonal signals to the rest of the body, including the ovaries. So it would be absolutely plausible to me that there is a connection there. And so addressing stress from the top downdown level, I believe can have a potentially very positive effect on someone's gynecologic well-being. I think that's so brilliant because I was brought up with this idea that the mind and body are completely separate. I understand that's partly like maybe a bit

of a British stiff upper lip the way I was brought up in these other sort of things, but they had nothing to do with each other. And I think about my grandparents, particularly my grandmother who I love so much, she was definitely like, you know, she'd been through the war. It was like, you don't make a fuss, you just keep going. And so the idea that these two could be in any way linked

is very alien really to how I was brought up. But what's interesting is, you know, you're talking about it, like serious doctors and scientists talk about this idea that you could meditate, it might actually change what's going on inside your ovaries. It's sort of mad and I love it. I believe that. I mean, the mind-body connection is real.

Jen, I'd like to just quickly try and summarize, please correct me if I got anything wrong. First, you described what you cover, and I think struck by just how many different parts of a woman's health actually is sort of tied back to what you're responsible for. You talked about this idea that there should be this thing called nutritional gynecology,

and that really affects your health, and it shouldn't just be this old world of like, either you're taking medicines or nothing else. We touched briefly on the vaginal microbiome as one of these examples of going beyond just thinking about medicine and I think my main takeaway is that if we think that the gut microbiome is still quite early in its understanding we really really don't understand very much about vaginal microbiome but interestingly you said your patients tend to be in these two groups, ones where somehow it's all living in this very happy symbiosis and they say,

I'm never having any problems. And another group that's saying, I'm just constantly having infections of various different thoughts. And I really struck by the analogy with what you tend to see with the gut with people who are having gut problems, all these different issues. And what we know there is like often if you can over time shift your food, you can really fix it. So I think that's really interesting. I'd love to come back to that on the whole podcast at some point, Sarah,

we should definitely do that. You then talked about diet affecting the four P's perimenopause, puberty, pregnancy, and PCOS. And that basically it can have a big impact across all of these areas. You said something that really shocked me, which is that because of the way that the food we eat is changing, actually girls are going into puberty earlier than they did before. And so there's like this real direct impact of like this very high level of ultra processed food that we're eating and something like so measurable like that, which is a bit terrifying. You talked about the diet you've had for like years before you get pregnant can really have

an impact on the baby. And it's a lot of pressure around this, but still is something to be aware of. Whereas whether or not has a big impact on fertility is not in fact, the science is not as strong as maybe some people have been saying. So to be wary, it sounded like some of the claims about diet for infertility. PCOS, which I'd heard of, but didn't really have any idea what it was, is affecting one in 10 women with a lot of really serious sounding conditions. And you said, if you're able to lose 5% of your weight,

it can have a big positive impact, but that's really hard. So the reality is probably thinking about improving your diet is probably the best thing you can do, but this isn't going to solve everything. We touched on endometriosis, which does not begin with a P, but apparently is another one in 10 and with I think a similar message and again, a message that this stuff is complicated and that you need to get to a gynecologist to deal with this. And then coming through at the end to sort of what is the diet, I think the thing that you said that I thought was brilliant is

the best gynecological diet is the same as the best brain health diet, is the same as the best heart health diet. It's basically like this really healthy diet for you. It's about whole foods. It's about not having the ultra processed foods that are surrounding ourselves. And then you said something which I haven't heard someone say before, which is think about yourself as an ongoing science experiment, right? Like in a sense, there's all this science about everybody else, but you are unique. And Zoe, we believe in that a lot.

We see this huge variation. So test yourself, you know, try getting the 30 plants a week that you know has this. And actually you may well be able to feel it. And in fact, you mentioned a whole bunch of potential ways that you might be able to measure that as a woman that I would not have thought of. So it's like other ways that you might be able to see this change. And then finally, you said something I definitely wasn't expecting you say, Jen, after this very serious scientific and medical take all the way through is when I asked about what else you could do to support your gynecological

health, I thought you were going to talk about like sleep or exercise and you went to meditation and you said the mind body link is real and you really believe that that can make a difference. That was a perfect summary, Jonathan. Gosh, we've covered a lot of great stuff. And I think the words that stick in my mind in terms of premise and underlying conceptual background behind everything we've talked about is holistic and not in the sense that I'm swinging a crystal over anyone's head or body,

but that we're connecting the dots between organ systems in the organism and in the environment. That to me is what holistic means from a nutritional and medical standpoint, gynecologic standpoint. And the other concept that was the 800 pound gorilla in the room, if you will, is inflammation. Because all of the things we talked about, all of the conditions, as well as all of the remedies or approaches, if you will, are either there with an inflammatory component or because of inflammation or reduce or prevent inflammation. And meditation is part of that.

Meditation is part of the triage kit to lower systemic and cellular inflammation. There's science to support that and it's behavioral. Jen, thank you so much. Really appreciate it. I hope we can have you come back again in the future. Thank you guys for having me. Thank you. Now, if you listen to the show regularly, you already believe that changing how you eat can transform your health, but you can only do so much with general advice from a weekly podcast.

If you want to feel much better now and be on the path to live many more healthy years, you need something more. And that's why more than 100,000 members trust Zoe each day to help them make the smartest food choices. Combining our world-leading science with your Zoey test results, Zoey is your daily companion to better health for life. So how does it work?

Zoey membership starts with at-home testing to understand your unique body. Then Zoey's app is your health coach using weekly check-ins and daily guidance to help you shift your food choices to steadily improve your health. I rely on Zoey's advice every day, and truly it has transformed how I feel. Will you give Zoe a try?

The first step is easy. Take our free quiz to find out what Zoe membership could do for you. Simply go to zoe.com slash podcast, where as a podcast listener, you'll get 10% off. As always, I'm your host, Jonathan Wolff. Zoey's Science and Nutrition is produced by Julie Pinero, Sam Durham, and Richard Willem. The Zoey's Science and Nutrition podcast is not medical advice, and if you have any medical concerns, please consult your doctor. See you next time. Thanks for watching!