Why Younger Women Are Getting Breast Cancer at Record Rates (And How to Reduce Your Risk)

You know, mammograms pick up 75 to 85% of breast cancers. More than half of women above age 40 who had mammogram had dense breast tissue. The more dense the breast tissue is, the harder it is to catch that cancer on breast imaging. Dense breast tissue is white. Cancer lights up as white under— when you look at mammograms, that, that little lesion, white lesion, gets lost in this, in the background. Women, if you have Dense breast tissue, you need to ask for 3D mammogram because 2D mammogram is a 2D x-ray of the breast, and the radiologist will just say on the report, well, we didn't see anything. That doesn't mean there's no cancer.

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Thank you for having me.

Well, we're going to talk about a topic today that terrifies most women that you unfortunately experienced, which is breast cancer. And unfortunately, it seems to be increasing, and particularly in younger women who are actually having worse outcomes and higher mortality, meaning they're dying from This is kind of scary. And personally, I've had some very close friends who've had this and died from it, you know, young, in their 30s, 40s. And the question is, why? And why are we missing it? And why are these cancers being caught late? You know, there's a screening protocol, it's now 40 years old, every 2 years, but still.

And I'm here to debate that.

Okay.

I want to start by talking about access, right? 50% of counties in this country don't have an OB-GYN. 5-0, 50%. So that's the first problem. Patients, they find lumps, they don't even— they can't even go see an OB-GYN. That's number one. When women get to that medical office, whether it's their primary care or gynecologist, they're more likely to be dismissed. Their pain is minimized, their symptoms are completely ignored, and that's a fact. So I think a lot of this That's the first— that's where we start. That's the baseline. Standard of care, I always say, in women's health is underground. Mm-hmm. We're not really— we're not doing any favor to any of our patients right now. The, you know, women think that they don't need to have a mammogram until age 40. That is so misleading, in my opinion. Every single woman— and let's go back to the incidence— breast cancer affects 1 in 8 women, right? So an average American woman has a 12.5% chance of getting breast cancer. If I told you you're about to board a plane with your family members that has a 12.5% chance of crashing, what would you say?

I'd say don't get on that plane.

Don't get on that plane. But when I say an average American has a 12.5% chance of getting breast cancer, what I hear is, it's okay, I don't have it in my family, I'm not going to get breast cancer. And that's the misinformation, and that's why I love talking about this topic.

Yeah, people think, oh, so I have a BRCA gene or family history, then I have to worry about it, but you're saying no.

No. 85% of women who get breast cancer don't have it in their family. I had no family history of any cancers. I didn't have a genetic mutation. I was very healthy. I never smoked. I've never done drugs. I had maybe— I've had 20 alcoholic drinks all my life. I've always been thin. I used to exercise a ton when I was diagnosed with breast cancer. You can't really say, you know, I don't have it in my family, so I'm not at risk. So that's the first misconception that we need to address. The most important thing is obviously if you have family history, if you have dense breast tissue, if you're— if you have a genetic mutation, if you've had a biopsy that shows atypia, if you had radiation to your chest, At a young age, if you're overweight, if you're drinking a lot of alcohol, those are all risk factors that can increase your lifetime risk of breast cancer beyond that 12.5%.

So is not breastfeeding?

Absolutely.

So is having babies late? Early pregnancy.

So is not having a lot of babies? Right, exactly.

Because women who have a lot of babies and breastfed a lot don't seem to get as much breast cancer, right?

Right. So there's so many risk factors, and that's why one of my missions in life is I always say, if you know your first name, if you know your last name and your date of birth, You need to know your lifetime risk of breast cancer. Literally, I go to a party and I see— I always want to see a number above everyone's head.

And how do you calculate that?

So I recommend using the Tyrakusic risk assessment tool. It's a tool we use that calculates— you basically enter your age, your height, your weight, the density of your breasts, your family history, age at menarche, age at menopause, whether you've had any abnormal breast biopsies like atypical lobular hyperplasia, Some basic questions. And at the end, it calculates your lifetime risk of breast cancer. If that number is 20% or more, I want to change that in Function Health for you. I want every woman to have their lifetime risk calculated. Yeah. I would love to help you do that, honestly. Amazing. Because anyone that has any platforms, I want to grab those women and say, calculate your lifetime risk of breast cancer. If that number is 20% or more, you do not start your imaging at age 40. You actually start it as early as age 30, and you get a mammogram. If you have dense breast tissue, you do an ultrasound. And for high-risk patients that fall above this 20-25%, we also add a breast MRI annually. So these are women who at 38, they show up with stage 3, 4 breast cancer because no one really calculated their lifetime risk of breast cancer. Yeah. I had no family history of cancer, I had no genetic mutation, but my lifetime risk was high based on this biopsy they did in my breast that showed atypical lobular hyperplasia that pushed my lifetime risk to 37%. But if you look, my doctor would look at me and say, you're going to be okay. Look at you, you have no family history, you have no genetic mutation, don't worry about this atypical lobular hyperplasia. Yes, I worry about it, and I don't want to come back in 6 months.

So what happened? You were 48, you had atypical cells in your breast, but your imaging didn't show it?

I had a negative mammogram, I had negative ultrasound, and my MRI was read as benign. Well, looking back, my lesion was sitting in my MRI, and it's okay. People can— radiologists can miss, you know, can, you know, we're not robots, we can make mistakes.

But you insisted to have a biopsy, that's why you found it?

No, I went for my mammogram and they said you need a biopsy. So they biopsied it. They biopsied my left breast. They called me, they said it's atypical lobular hyperplasia. They did an excisional biopsy, removed that lump, and they told me to come back in 6 months. I always calculate everyone's lifetime risk of breast cancer in my office. So at that point, I had no reason calculating mine because I had no risk factors. But as soon as that atypia showed up, I went back to my office and I calculated my lifetime risk. And Mark, I almost fell off my chair when I saw that number, it popped out 37%. And I'm like, wait, what? That's a mistake. Me? No. Look at me. I'm not going to get breast cancer. And I recalculated it and it was 37%. And that's when I called my breast surgeon and I said, you told me to come back in 6 months. I have 3 little kids at home. I have a busy practice. I love my husband. I love my life. I don't have time for breast cancer. Yeah. I already have implants, take my breasts off, put bigger implants in, let me go on with my life. That's when they started telling me I'm being anxious, I'm being too nervous, why am I so paranoid, you know, everything that women hear again. And for me—

Women are dismissed typically by medicine.

I mean, if I get dismissed, if I'm told I'm crazy, I literally have had colleagues who called me crazy, anxious, paranoid. I heard it all, but it didn't matter. I was so laser-focused. I finally found a doctor who was willing to do my double mastectomy. And the day before surgery, she's like, you know, I'm doing this, but it's against my wish. And I'm like, why? Why so much resistance? It's my body. Why do you care so much? You know what she said? We have really good chemo for breast cancer.

Wow.

Do you understand that?

Wow.

I don't want chemo. You go get chemo. I don't have— I don't want to get chemo. I don't want to put that poison in my body. So she did it. I almost died because the surgery was 10 hours. I bled out. You would appreciate this. My hemoglobin the day after surgery was 5. Dang. And my blood pressure was 60 over 20. It took them 2 days to transfuse me with blood. I don't even have a memory of that. But one thing I remember, the minute they woke me up from anesthesia and my husband came to hug me, the first thing I told him is, go home, tell our girls, Mommy will never come home telling them she has breast cancer. Go tell the kids that I did this. Of course, a week later I'm in the car back-to-school shopping with my husband and I get a call.

You get a pathology report.

Yep, and you know when your doctor calls you, it's never good. When the doctor says, I got off the phone from pathology, my brain shut down because I knew what he was going to say. All this time they were digging in my left breast. My cancer was actually invasive stage 1. in my right breast. People say, why did you pick a double mastectomy? It's so aggressive. It's this, it's that. You've obviously never had a mammogram and you've never had a breast MRI. But you go, you have to take like literally half a day off. You go sit, they put you in these machines, they squeeze your breasts, they put you in an MRI, they give you contrast, and then you have to wait 4 or 5 days for one phone call and you still don't know. And in my case, I was right whether or not they can read it correctly, right? Because it's human error anyways involved in it. So my I felt like my life was in the hands of these radiologists reading these, and I didn't want to put myself every six months through these imaging. And that's why I decided to do the double mastectomy. But it doesn't end there. Like two weeks later, and I was I was still even though I was upset, and you know my doctor who didn't want to do this for me and kept calling me, you know told me it's a. don't do it, you're paranoid. She called me and, because these hospitals turned upside down when my path report came back, and she told me, Thais, you're so lucky. I never forget where I was standing in my room when she called me. She's like, you're so lucky we caught this early.

You caught it early.

I'm like—

Not they.

I'm like, lucky? What? I'm not lucky. No one with cancer thinks they're lucky. Do you know what I'm saying? Because it's always in the back of your head. When someone tells you you have cancer, you go to the worst-case scenario.

And this is such an important lesson for people. You know, you were a doctor, you were a health

advocate,

you're a women's health advocate. You had a funny little thing in your one breast. You had a biopsy, you made your— calculate your risk. You made a pretty radical decision. You know, like Angelina Jolie had the breast cancer gene, so she took off both her breasts, and that was a big public event that got people's attention, but you didn't have that. You were like, I just don't want to take the risk, which is a pretty aggressive decision for most women. But it turns out that you were right and that there was something there. And I think for women listening, women can have a completely normal mammogram. You had a normal MRI. What are the limitations of mammograms, particularly for younger women who have denser breasts? Where are the problems with this? Because people think, I have a mammogram, it's normal, I'm okay. Not necessarily.

No. And, uh, you know, mammograms pick up 75 to 85% of breast cancers, right? Let's start there. So we're still missing a lot of cancers screening women. Like 15 to 25% of women with cancer will still go out, like just like myself, and they're told they have a negative mammogram. More than half of women above age 40 who had mammogram had dense breast tissue. What does dense breast tissue mean? The more dense the breast tissue is, the harder it is to catch that cancer on breast imaging. Dense breast tissue is white. Cancer lights up as white under— when you look at mammograms. So when someone has fatty breasts, right, and they don't have any dense breast tissue, which 10% of women have fatty breasts, in this group of women, cancer is picked up easily on mammogram. I had extremely dense breast, extremely dense breast, there's so much background noise that that little lesion, white lesion, gets lost in this, in the background of dense breast tissue. Yeah. So for patients like myself, A, women, if you have dense breast tissue, you need to ask for a 3D mammogram because 2D mammogram is a 2D X-ray of the breast and the radiologist will just say on the report, well, we didn't see anything. That doesn't mean there's no cancer. If you can't see something, if this window was muddy and you told me to describe the view, I wouldn't be able to describe it, right? But if you took a Windex and cleared it, I could see better. So as AI is improving and with 3D imaging, with adding breast ultrasound, it's that Windex that we can clear some of this and be able to see outside.

And the 3D mammograms is a better technology.

Yes.

But it's not something that's standard or people get

it. It is pretty much standard right now. And I would tell your listeners, if you, you know, and as of a few years ago, radiologists need to report on the density of the breast on the mammogram and recommend maybe a follow-up with additional breast imaging or a breast ultrasound, and for high-risk patients with a breast MRI afterwards. But if you look at your mammogram and it says dense breast and on top it says a 2D mammogram, next year go ask your doctor for a 3D. If you have dense breast tissue, ask for bilateral breast ultrasound. Calculate your lifetime risk by age 30. If that lifetime risk is 20% or more, Ask your doctor for a breast MRI. Unfortunately, a lot of doctors will give a pushback.

Can people calculate their risk on a website, or how do people calculate?

I have it on CMD, uh, on our podcast. It's free. They can literally go there. But before

that, cmd.com,

cmdpodcast.com,

cmdpodcast.com, right? Because people are going to say, how do I find that out? They want to know.

They want to know, and they should. And that's why I literally want function health to do that for every woman, every single woman that you're sending live. I'll work on it. It's a great idea. I love that. I'll help you with it. I mean, you should do it. It's a— you will see, you will save millions of lives doing this. Because, you know, someone like me with no family history, no risk factors, my risk was still 37%. And, you know, people say it's so aggressive to remove your breasts, but 37% chance of boarding a plane—

That's going to crash.

That's going to crash. That's not crazy. If I say I don't want to board this plane and someone's calling me crazy, how would that make you feel? If you're about to board a plane and I say you have a 37% chance of crashing and you say I don't want to board, it's I don't want to go, I don't want to take my kids on that plane, and people called you crazy, how would you feel?

I would think they're They're crazy. Crazy.

It's like, you're crazy.

I'm not crazy.

You're crazy. You're the crazy one.

Yeah, exactly. Exactly. Wow.

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And I don't think people have heard about this lifetime risk calculator. There are calculators for heart disease and other things, but this is a relatively unknown thing. And I don't think most doctors know about it. And I think it's a useful tool. So I think, you know, I don't think you're saying everybody with a High risk should go get their breasts lopped off. Oh, God, no. But, I think it's important to really be careful about screening, understanding what's happening. And, there's new diagnostics. At Function Health, we use the Galleri test, which is a multi-cancer early detection test. It's not perfect, but it picks things up. There's new tests. MD Anderson is providing proteomic tests that are looking at risk including breast cancer to help get ahead of this. And, I think better early— I always say cancer's worst enemy Is early detection. And there's still some emerging cancer therapies that are really optimistic and improving, but still, cancer is not a great diagnosis and it's not well treated by traditional medicine, and we're getting more and more of it.

I want to talk to you before we leave this topic of genetic testing.

Yeah, I was going to bring that up. Because I—

that was your next question? I love that. Because I feel like at the latest by 25, Every single woman with family history of not just breast cancer and ovarian cancer, pancreatic cancer, prostate cancer, ask your doctor for genetic cancer testing. When we do genetic cancer testing, they look at maybe 48 to 80, 90 cancer-causing genes. When it comes to breast cancer, there's about 11 single gene mutations that are pathogenic, like the BRCA, PALB2, CHEK2, ATM gene. Yeah. And the list goes on and on. And these are gene mutations that will increase someone's lifetime risk of breast cancer. It doesn't mean they're going to get breast cancer, but it can significantly increase that risk from like 25% to 35% to 50% to 80%. So it's very important by 25, in my office, I used to do it at 25, but because of all this cancer that we're seeing, I've dropped it to about 20. With the patient consent, obviously, I do genetic cancer testing because I don't want to miss anything.

Just so people understand, everybody out there has heard about the BRCA gene, or most people have heard of it, which is the most common thing discussed around breast cancer. And, it was interesting, if you look at the data, like, in the '30s and '40s, that they were able to track some of this, that if you had that gene, your risk of cancer wasn't as high as it is now. Now, it's about 75% if you have that. And so that speaks to the fact, one, that there's environmental factors that play a role. And 2, what you were speaking about was what we call polygenic risk score, which is a really important concept that means that it's not just one gene that matters, it's the cocktail of genes that all influence your risk. And we're able to do these around heart disease, around cancer now, and they're very helpful.

And they're very helpful for breast cancer. So you can do your genetic cancer test and look for these gene mutations like the ones I listed, but that's less than 10% of women with breast cancer will have that. A lot of us are walking around with this high polygenic risk score, meaning we have these variants in our genes that individually, these are markers that by themselves, they don't have much power, but someone like me can walk around with a lot of these markers. And if I'm not mistaken, right now they're checking anywhere from 86 to 305 markers, variants for the polygenic risk score, and they report on that. And breast cancer is one of it. If you fall in that bell curve above 90th percentile for the polygenic risk score, that can increase your risk. So someone like me, actually, I didn't have any genetic mutations. I didn't have any family history. I really didn't have any obvious risk factors, but if you look at my polygenic risk score, it flags at high risk for breast cancer, which means I had a lot of these variants in my DNA.

And there are also a lot of labs that can be really helpful besides just the genetic screening. Can you maybe touch on some of the things that play a role in breast cancer?

You know what, I want to clarify one thing. There's no blood test that will tell you if you're going to get breast cancer or if you have breast cancer right now.

But there are things in your body that increase your risk. That's great.

Right. But, you know, I think we talked about this, your metabolic dysfunction is huge, inflammation. I always tell my patients, if you want to reduce your risk of any cancers, not just breast cancer, there are certain lifestyle changes you need to do. The basics: sleep 7 hours, exercise every day, optimize your metabolic health. You know, we talked about this, majority of people on this planet will go through life and will have metabolic dysfunction. I'm sitting here, you know, my entire mom's side of the family, they're pre-diabetic and diabetic. So we are, we have some, you know, your genetics load the gun, but your environment— Pulls the trigger. Pulls the trigger. So optimizing your metabolic dysfunction, lowering inflammation, I think is huge.

And you can measure these things like insulin, CRP.

Yeah, I do that every single day. Every single patient, literally, besides the hormone panels that I run, I check their hemoglobin A1c, I check their lipid panels. We talked about this. I check ApoB, lipoprotein, high-sensitivity CRP, homocysteine, and their vitamins, vitamin B12, vitamin D, ferritin, iron. All these play a role in all this. All of it. So it's not just one thing, it's a combination of everything. And

we test all that at Function Health, so you really can get a comprehensive picture.

Me too. I'm so proud of you guys, honestly, for provide, you know, I do it for my little office. You're doing it for, for, for people who have NOAH, which is unbelievable. And I'm so proud of you guys for doing that. And, um, honestly, I will tell you, I've practiced— I've been in private practice in my own little world for 25 years. I've never lost a patient under my care to cancer who did what I told them to do. That's amazing. I— but I do everything. I do genetic testing. I do this, uh, liquid biopsy that we talked about. I, uh, I always order the total body MRI on my patients. You know, after 45, I always recommend it, obviously. And

we do that with function too. We can do it as a full body MRI.

I love that.

It's very affordable.

Yes. Every single patient of mine has had their lifetime risk calculated. Every single patient of mine, if they need genetic testing, it's already done in their chart. If they're at high risk, they have an order for ultrasound, 3D mammogram. I fight with insurance companies if they have a high lifetime risk to get their MRIs approved. I optimize their metabolic dysfunction. I mean, I'm a gynecologist and I'm running ApoB and lipoprotein. I don't have time to do that. And my physician assistants who work for me, they're frustrated because I do so many labs on every single patient. But I do it because nobody else is doing it.

Yeah, it's like you wouldn't be like driving your car with blinders on. You want to see what's going on. Like, you need to see the spectrum. I want to sort of dive into a little bit of this kind of science around why this is happening because I've been in medicine 40 years and I don't remember this level of breast cancer in the younger population.

And, what really seems to be interesting is that these are estrogen-related cancers primarily because there's many different kinds of breast cancer, but these are estrogen receptor-positive driven cancers. And, what we learn in functional medicine is this concept of estrogen dominance. Or excess, and it's either relative or absolute. And a lot of things affect your lifetime exposure to estrogen, which is when you had your puberty, and women are getting it earlier than ever. Some girls get it at 8 now.

When they give birth, the first age of birth.

The holidays, right? They're

having less pregnancies. They may not be breastfeeding. All these increase your risk of breast cancer. And this is not to shame women or to make them feel bad, but these are just the facts. And then, and then there's obesity on top of that, which is a huge driver of cancer in general, particularly breast cancer because of insulin resistance. Then we have lack of exercise, which increases your risk of breast cancer. And we have alcohol consumption, which increases your risk. I mean, I was shocked when I remember reading in JAMA that was like, if women had one glass of wine a day, their risk of breast cancer was increased by 40%. Right. That's just one glass a day. Then on top of that, we have all these environmental chemicals that are what we call xenoestrogens or foreign estrogens that are very powerful estrogen-mimicking compounds that bind estrogen receptors, whether they're PCBs or phthalates. They're in makeup, they're in sunblock, they're in face creams, they're in plastic. They're pretty much everywhere. And these are petrochemical-derived products. These are huge toxic burden. PCBs, BPA, phthalates, parabens, all this stuff. And then obviously there's heavy metals. So all this stuff is going on at the same time. All day,

And

then our microbiome plays a huge role in cancer. Again, it's another big factor. Our microbiomes, because of our ultra-processed diet, have changed. Our guts aren't healthy. And there's a whole estrogen processing system in your gut with bacteria. If they're the right bacteria, it works. If they're not, it doesn't. And you recirculate the estrogens and increase your estrogen. And this is called the estrobolome. It's a whole field of medicine, just understanding the way the microbiome is related to estrogen. your estrogen metabolism. And all in all, we see these really increasing numbers of estrogen symptoms, even things like PMS or

fibroids

or

PMDD.

All these things are related to imbalances in estrogen. And there's ways to treat it and diagnose it that I think most people aren't really aware of.

I want you to open an office right next to me. I found my twin. You know, I always call my office the office of dismissed women. If you spend a day with me in my office, you will go home with a broken heart. These are women who travel from everywhere and they only come— they already know. They know they have endometriosis. They know they have PMOS. They know they're at risk for breast cancer and someone's not writing an MRI order for them. They want genetic testing. The dismissal, So when I started this podcast and I said access is one issue, but once they, even when they have access and they end up in that medical office, their symptoms are dismissed and the right tests are not ordered for them. Let's start with even, you were talking about other cancers, pelvic ultrasound. Do you know how long it takes to do a vaginal ultrasound?

5 minutes?

No.

1 minute?

1 minute. Yeah. 1 minute if you've done it for 25 years or 30 years. It takes me 1 minute, right? It's an uphill battle for women to get a pelvic ultrasound.

Yeah. Just so people are listening, we learn in medical school that in order to check a woman's reproductive health, you do a pelvic exam, which is where you use your one finger in the vagina or one hand in the vagina, one on the abdomen, and you feel around and you try to feel the ovaries, you try to feel the uterus, you try to— it's like kind of Braille. Instead of sticking an ultrasound in the vagina and actually being able to see everything in 3D clearly what's going on.

What's going on?

Yeah, and it's a device that most gynecologists have in their office.

It takes, like you said, I thought it was 5 minutes, it takes 1 minute. And it's very inexpensive, it's very easy, it's very fast, and there's no reason it shouldn't be part of an annual screening exam.

But you know what? It's not in every gynecologist's office. That's the problem. These people still get a prescription if the doctor writes for it. Women, I think women should get a pelvic ultrasound every single year. As soon as you become sexually active, get that transvaginal ultrasound. If I don't do an ultrasound, if you decline an ultrasound in my office, it's like you're covering my eyes and tell me to drive. I need to see, do you have a polyp? Do you have fibroids? Do you have a septum? Do you have— do I see endometriomas on your ovaries? Do you have ovarian cysts? What is going on? I need to see, do you have polycystic ovaries? On ultrasound. There's so much I can tell.

And there's no radiation.

Nothing. Very safe to do. And bimanual exam is very invasive. Yeah. To have a guy gynecologist to put their fingers inside, like, it's uncomfortable. I don't want anyone doing that to my daughters. Yeah. So why not just be more civilized and put an ultrasound? You're going to get— what is bimanual exam going to tell you? You can miss over— Yeah, those metal speculums are terrible. Wasn't it terrible? It's uncomfortable. It's uncomfortable for the doctor doing it. It's uncomfortable for the patient, and you really don't get that much information from it. So it's really sad. So I would say start with basics when it comes to women. A, listen to them. B, don't dismiss what they're telling you. Women are very in tune with their bodies. If they tell you— if a woman comes to my office and says something's wrong, almost always something's wrong. Women are not crazy. We're far from crazy.

Well, it actually harkens back to the early 1900s when women were diagnosed with hysteria. It was a medical diagnosis in their diagnostic codebook. Hysteria derives from the word hysterectomy or uterus. So it's like, what? Women are hysterical. That's actually a pejorative against women that people are talking about all the day. No,

no, I've got to change that. That's got to change. It's like, it's unacceptable.

Yeah. No, I think as a doctor, uh, who's been practicing medicine for 40 years, I'm old. Um, it's, it's shocking to me how, uh, doctors don't often listen carefully to their patients because they will, they will usually tell you what's wrong with them, or they'll tell you the clues that will help you figure out what's wrong with them if you ask enough questions. And I think it's easy to say, oh, we know better. We're dismissing this because it's nothing. And I always said to my, my, my talks, I would say, well, you go to your doctor, you know something's wrong, you feel bad, something's off. The doctor says, well, I've done your labs, I've examined you, which means he's done like 20 different lab tests, not 150, and everything seems fine, so maybe take some Prozac. And I said, there's only one of two possibilities in that situation. One, your doctor's missing something, or you're crazy. And I don't think most people are crazy. So it's usually—

we're not crazy.

It's usually doctors missing something.

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And I think it's so important. I would love you to sort of talk a little bit more about how to reduce your risk because, you know, we've talked about this early screening. We talked about your lifetime risk for breast cancer. We talked about mammograms, 3D mammograms, breast MRIs, ultrasounds. All this is really important. And this is about detection, but I want to talk about addressing the factors that are increasing the risk because it's not because we don't have good detection that women are getting cancers earlier and dying of them at a higher rate. It's because of something else. So I want to get into the something else. I touched on a lot of these issues, but I'd love you to sort of dive into how do women address these fundamental drivers of breast cancer? Because people who think of cancer as just something, I got cancer, like I got a virus. No, it's something that develops from a foundation of disturbances in your biology that can be modified if you know what they are and if you look for them. So can you talk to us about that?

I think environmental factors are huge when it comes to breast cancer. Obviously, you know, there are certain factors like your genetics, your density of your breasts, there are certain things you can't really change, but there are other factors that you can address that will lower your chances of getting breast cancer. If you're overweight, drop your weight. If you're not exercising, exercise. If you're stressed and not sleeping, address that. If you're not eating healthy food, if you're eating a lot of processed food, deal with that. Toxins. We talked about how we're all exposed to toxins from the air we breathe to the water we drink in plastic bottles to the processed foods we eat to all the products that we put on our skin. So this is just 4 ways of getting toxins in your body. It's hard to live in a world where you have zero exposure, but I feel like if you address all of it a little bit, from your sleep to your exercise to your diet to your hydration to your stress level to your sleep to your metabolic health, lowering your inflammatory markers, you know, like— And your toxic levels. And your toxic levels. All of it, all of it. And, you know, for example—

Alcohol probably is a trigger.

Alcohol, oh my God, huge. Alcohol, smoking. And, you know, like I treat a lot of PMOS patients and these, you know, PMOS is the leading cause of infertility.

And PMOS is?

It's a new name for the old PCOS. You know, it took us years to bring awareness to PCOS and then they changed the name to PMOS, which is better because Polycystic ovary syndrome does not describe the condition. It's actually polyendocrine metabolic ovarian syndrome. What does that mean? PMOS, you know, it's the leading cause of infertility, one of the leading with endometriosis.

It affects 10 to 13% of women.

Majority of these women go through life, they're never diagnosed. These are women, in order to diagnose it, you need to meet 2 out of the 3 criteria: irregular period, PCOS-looking ovaries on ultrasound or elevated AMH. And the third criteria is symptoms of high testosterone. It could be facial hair, body hair, acne, hair thinning. So you need to meet 2 out of the 3 criteria. But PMOS patients are anxious, they're depressed, they have PMS, they have PMDD, they have mood disorder. 75% of them gain weight. They can't lose it. They have a really hard time losing it. They're at a high risk for eating disorder. You know what I always say? You want to find PMOS patients? Go knock on the doors of eating disorder centers. They're all sitting back there. That's right. But instead of someone saying, let me address your metabolic dysfunction, what do they do? They bring him a psychiatrist and they get treated with Zoloft and Lexapro and this and that, but no one's addressing their underlying metabolic. It's really, really sad and it's the leading cause of infertility. If men had a leading cause of infertility and majority of them would go through life not diagnosed,

It's crazy to think about.

It would never happen, right?

No, you're right. I mean, I think this is important. I've been saying for literally decades, probably 30 years, that PCOS is not an ovarian problem. It's a metabolic problem. And it's really a nutritional problem primarily. And it shouldn't be treated as if it's an ovarian problem. And they give people metformin or spironolactone, or they give them the birth control pill, or all these things that actually just May mask the symptoms instead of actually dealing with the real issue and helping women get pregnant.

I actually listened— I was listening to this huge podcast and they had a gynecologist, and the host asked the gynecologist, so what is the treatment for PMOS? She said birth control. I wanted to fall off my chair, like, what? No, the underlying condition is metabolic dysfunction. Did you know that?

And what you mean by that is insulin resistance.

Insulin resistance.

This whole spectrum of Insulin resistance, prediabetes, type 2 diabetes, that's the whole spectrum.

Because what happens with these patients, because of that insulin resistance, when they eat carbohydrates and their body releases insulin, their cells are insulin resistant. So instead of the sugar going into the cell and turning into energy, it bounces in the blood, pushes their insulin to go up. In simple terms, this spike in insulin causes these symptoms or the cascade of events in their body. This high insulin tells their liver, take the sugar and store it as fat. But the fat that they store is visceral fat. It's highly inflammatory. It causes more insulin resistance, brain fog, fatigue, all of it. The high insulin stimulates their theca cells in the ovary to pump out testosterone. Yeah. Testosterone is toxic to these little follicles. So these follicles, these antral follicles that come to the surface every month, and one of them becomes dominant and ovulates, that whole thing with testosterone around, these follicles freeze. That's why you get that polycystic look. These are not cysts, these are sack of pearls inside the ovary. And what happens, this testosterone not only is toxic to these follicles, so ovulation goes away, the periods become irregular.

And heavier, and they get more bleeding, and they get more iron deficiency.

Exactly. But they also get facial hair, body hair, and acne. Why would a 30-year-old have acne?

They go bald, get pimples, and get facial hair.

Yes. It's not good. And then you have a condition. We already know inflammation's high. We already know androgen is high. We already know there's no ovulation, so progesterones are down. And we know these follicles are secreting erratic estrogen. So of course, all of it affects your limbic system. Your limbic system, which is your emotional headquarter, in order to be calm, it needs high progesterone, normal amount of estrogen, testosterone, and low inflammation. All of it is the opposite in a PMOS patient. But instead of someone addressing their metabolic dysfunction, that first domino that dropped was their metabolic dysfunction and insulin resistance. No one addresses that. They get the Zoloft, they get the spironolactone from the dermatologist, Zoloft from the psychiatrist, birth control from the OB-GYN. Gynecologist. But no one looks at these patients holistically. say, wait a minute, these are not separate. These are all part of one condition. Address their metabolic— address their— look at their lipid panel, look at their high-sensitivity CRP. These patients have so much inflammation. And from my studies, 61% of PMOS patients have endometriosis.

Yeah.

And another leading cause of infertility. It takes doctors 9 to 11 years to diagnose these patients. And so think of this one woman who's gaining weight, who has irregular periods, who has all these symptoms, painful periods, A, doesn't have access to an OB-GYN, and then when she gets to that office, the doctor says, there's nothing wrong with you.

I just had a patient like this. It was quite amazing. She was 28. She had high, very high insulin of like, I think, 30 fasting. She had very high testosterone. She was quite anemic. Her iron stores, her ferritin was 3, it should be 45 because she'd been having heavy periods because she wasn't ovulating and making progesterone. So, she wasn't regulating her cycles. She had anxiety, she had depression because progesterone is a relaxation hormone. And, when you don't ovulate, you don't make progesterone because you were talking pretty fast. I'm just going to slow it down a little bit. Sorry. And so, people, women who have low progesterone, too much estrogen, creates emotional dysregulation, not to mention all these other factors. And, you know, obviously she had, um, uh, you know, lots of inflammation, high CRP, and all these things going on that were all indicative of, of this metabolic syndrome. And I basically treated her with just diet and a few simple supplements and exercise, and her testosterone went back to normal, her insulin went back to normal, her, uh, LH/FSH ratio went back back to normal. Her progesterone started coming up, she started ovulating again. And we didn't give her any drugs. That's interesting. I didn't give her any drugs. And the problem is most doctors don't know how to prescribe food or prescribe exercise. It's not like, eat better, exercise more. That's not helpful. Have 3 balanced meals a day. What's that? How do you do it? What do you eat? I think there's just such a lack of nutrition training for physicians and These are nutritional diseases.

For anyone listening, I would say I have a platform with an easy test. Obviously, I can't diagnose people online, but it's free. If you're listening to this podcast and you have irregular periods, you're gaining weight, you have acne, hair loss, facial hair, body hair, you have disordered eating, eating disorder, fertility issues, take the quiz. I can tell them whether or not, by answering a few questions, whether or not they have the likelihood of having PMOS. And if they do, I've created this amazing supplement with vitamin D, with an acetal blend, with wild mulberry, all this stuff that will address their underlying metabolic dysfunction, inflammation. One of the most important things for PMOS patients, walk after each meal. Go for a walk, simple things.

And it's true because I think there's all the history that'll help you, and it's really important to start there. But lab testing is now so affordable through Function Health, and we test all these We test your LH, your FSH ratio, your estrogen. We check for inflammation. We check for insulin levels. We check for A1C. We check for your lipid particle size and number, which reflects all that. We check for your vitamin D. We check for your iron. We check for B vitamin status. We check for all the things that regulate all these pathways. And we can actually fix them if we find out what's going on. And you'll get a clear plan of what to do and what's going on. And these are things that even if your doctor's not helping you, because by the way, The doctor's not going to give you anything except drugs. So the rest of the stuff you do on your own. What you eat, exercise, your lifestyle, supplements— these are things you don't need a doctor for if you actually know what to do.

So here's— I want to add another thing to function health.

What?

When you have a PMOS patient, please screen them for endometriosis because the gynecologists are not doing it.

That's not a blood test.

It's not. Well, there is a blood test now, uh, it's called I had her Resolve and it was just released. It's not public. I mean, most doctors don't have access to it yet, but soon they will. It's a blood test. It picks up 8 out of 10 patients.

What is it measuring?

Circulating mRNA, microRNAs. They add an AI algorithm to it and they tell you the likelihood, whether or not you have endometriosis, So it's actually a good test when it's positive. If it's negative, it doesn't mean you don't have it. By listening to women, you can get as accurate as 99% in diagnosing them with endometriosis, but this test is 80%. I'll take it. There is a saliva test right now. Hopefully it'll be available soon. It's 97% accurate.

So essentially what you're saying, Dr. A, is that The same things that help you prevent breast cancer will also address PCOS or PMOS now.

Endometriosis, all of them.

And it's basically eating a whole foods diet, getting off ultra-processed food, dialing way back on the starch and sugar. Alcohol is an occasional treat, like rarely. Exercising regularly, which really helps in metabolic health and hormonal health. Managing your stress levels, which affects your hormones. Managing Getting enough sleep, which affects your hormones, getting your lifestyle, reducing the toxic load by filtering your water, maybe an air filter, not using plastics, basic stuff. You know, I'm on the board of the Environmental Working Group, and there's whole guides on how to reduce your exposures from household cleaning products, from food, from skincare, and so forth. And not get obsessive about it, but if you just focus on these basic things, you can dramatically reduce these risks.

I mean, that's the right way to say it. You can dramatically reduce your risk. But it doesn't take your risk to zero. Endometriosis can still show up, PMOS can still show up, breast cancer can still show up, but you can do something about it to reduce this risk.

Yeah, it's really important. And I think your story in particular, as a doctor facing breast cancer yourself, identifying this when no one else was looking at it, being your own advocate, it sort of speaks to a really important point, which is you have to be CEO of your own health. That's why we created Function Health, so people can be the CEO of their own health. You know, I had a friend who developed rare cancer, and she was going to doctor after doctor, and she says she started a new company, which is Save My Ass Technologies, Inc. Basically, she realized she had to take ownership of her own health, and now she's still alive, you know, decades later. Oh, good for her. And she wasn't supposed to be. So, I think people can have a lot of power in understanding how their health works, what's going on underneath the hood, using tools like your breast cancer risk stratification questionnaire or Function Health lab testing to really understand what's happening in their bodies and not just sort of wait around for something to happen.

Absolutely.

In terms of metabolic markers that are really hormone markers that people should be testing, we kind of touched on a lot of them, but just kind of recap, what do you think are the most important things to look

So in my practice, in women in reproductive age, if I could check one thing, I would check their egg count, especially women who want to have children. It's a simple blood test. You can ask your primary. AMH. We do it at our function. I love that. AMH is very important, right? I just did a podcast with a young girl at 19 who had breast cancer. She had a CHEK2 mutation, no family history of breast cancer, and basically her AMH, when they went to freeze her eggs, her egg count was really low. And as I was interviewing her, she still didn't know why. And I'm like, did you have painful periods? She's like, well, now I don't because, you know, they're suppressing my ovulation. But prior to that, yes, very painful periods. And that endometriosis can destroy your egg count and quality. Mm-hmm. So AMH for reproductive women is very important. I, every year I check, do a full hormone panel on my patients. I check their testosterone because I see a lot of PMOS patients. Even though you don't have to have a high testosterone in the blood to get the diagnosis of PMOS, I still check— It's helpful. Free and total testosterone, DHEAS, to see what their stress level is. If they have irregular period, I check their prolactin. If they're overweight, I get a hemoglobin A1c. Every woman once a year, twice a year with me is vitamin D, a B12, iron, ferritin. I check high sensitivity CRP. I check homocysteine. I check their ApoB if they're fasting. They come in, I always do a full blood panel, and part of that is their ApoB and lipoprotein. ApoB, I always say, is a bucket of 4 particles that can cause plaque. And in that bucket, one of them is genetic, which is lipoprotein. 20% of women have it. No, if you have lipoprotein, that does increase your risk of stroke, heart attack, It can increase, you know, I check for ApoE4 for my perimenopausal women because that increases the risk of dementia, inflammation, stroke. And for those patients, actually, there's new data that if you give them hormone replacement, you can actually reduce the risk of dementia. So ApoE4-positive women, and 2% of women have 2 copies of the ApoE4.

That's a genetic risk factor for Alzheimer's.

For Alzheimer's, absolutely. So those women actually Actually, if you treat them early in perimenopause and menopause for 7 years with hormone replacement, there's new data that you can probably reduce the risk of dementia. Again, it's multifactorial. And

not if you start it later, when you start it right after.

Right.

Yeah.

Right, right.

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So people can find out this information now.

It can change their life.

Because if you go to your doctor and you ask for all these tests, their likely answer is going to be, it's not necessary, it's too expensive, it's going to chase down things that aren't important and make you scared. I would say nonsense, because information and knowledge is power. And if you don't know what's going on, you can't act on it. So I agree, I 100% agree with you. That's the conclusion I've come to as a doctor, which is opposite of what we were trained to do.

And honestly, for all your clients who are coming on Function Health, the other advantage that I see is that when you do a blood test through Quest, let's say, your ApoB of less than 90 is considered normal. It's not. Your AMH of 1 and above is normal. It's not. It's not normal. So you have to start looking at these. It can range in different ages.

Well, I want to, I want to sort of end by kind of doubling down on a bigger topic, which is hormone replacement therapy. Because essentially what we've been saying for the last almost hour is that excess estrogen stimulation from all the reasons, from being overweight to sugar to alcohol to environmental toxins, and so forth are increasing your risk of breast cancer. And yet we're also in a moment where the fear about hormone replacement therapy has reduced. It was triggered from the Women's Health Initiative, which was a little bit overinterpreted for that reason. Right. And now there's a sort of an increasing movement to put more women on hormone replacement therapy around perimenopause and menopause. So how do you reconcile those two and how do you handle that Threading the needle on that. I think, imagine people are having that question mark in their head.

And let me tell you, I feel like—

by the way, not just for the hormone replacement therapy, not just help your health, but it helps reduce osteoporosis, it helps your symptoms, it helps your sexual health, it helps cognitive health. I mean, there's so many benefits. It's kind of like, how do you thread that needle?

I feel, as a gynecologist, and I've been in women's health for 30 years now, I feel like the pendulum went from all the way to from this end, now it's swinging all the way to the other end. Mm-hmm. And there's a happy medium, right? I have patients who come to me and they're like, we heard on this podcast, you know, I've had an estrogen receptor breast cancer, but I've been cancer-free for, I don't know, 7 years, and now I want to do hormone replacement. I will not start that patient on hormones yet because especially estrogen receptor positive patients, you know, these are patients who 20 years down the line, they can show up with breast cancer again. So I think you have to personalize care. In my practice, if you come to my office and you want hormone replacement, I've already— I already know your lifetime risk of breast cancer. I've already done genetic testing if you have family history. So let's say I have a patient with ATM gene or CHEK2 who has a higher risk of breast cancer, who falls into the high-risk category. If that patient wants to have hormone replacement and I understand I couldn't have hormone replacement and I understand all All the bad things that can come with it. But then I might have a discussion. If your lifetime risk of breast cancer, let's say it's 50%, and with risk reduction, one option is to put these patients on tamoxifen, hormone blockers. If they take tamoxifen every day for 5 years, that you can reduce their risk by like 50% for the following 10 years.

But that throws them into menopause.

It has side effects, yeah, hot flashes, vaginal dryness, mood, fatigue, all of it, right? But you reduce their risk of breast cancer. So one discussion that I'm having with them is, here are your options for risk reduction. Let's say your lifetime risk is really high and it's at 50%. I can give you tamoxifen, but if I give you tamoxifen, I can't give you hormone replacement because they're doing the opposite. They're like, I'm trying to block the— Hormones. Hormones. I'm not going to give you hormones. Or the other option is, you know, let's say when I did my double mastectomy, if they didn't find cancer, I would have been on hormone replacement right now. Do you know, remove your breasts, reduce your risk, and then start hormone replacement. But if someone has an intermediate risk, low risk, they have symptoms, I'm all for hormone replacement. Give them hormone replacement. But I take every patient—

It's individualized.

It's individualized. It's not a blanket, everyone take hormone, nobody takes hormones. You know, it's the discussion again, like everything else we did. Look at their metabolic function, look at their inflammation, look at their family history, look at their genetics. Look at their polygenic risk score. Look at all of that, their cardiovascular health, and then decide whether or not they're a good candidate. But I love hormone replacement. I think for women who have the advantage of taking it, they should absolutely take it. The sooner you take it, the better it is. A lot of people think they have to wait for their periods to end and be menopausal. To start hormone replacement. It's not true. Average age of menopause is 51 and a half, 7 to 10 years, and the range is 45 to 55. 7 to 10 years before menopause, women can go through perimenopause. So if you're someone who at 45, let's say you're going to be menopausal, you could be perimenopausal in your late 30s, and there's nothing wrong with treating that patient with hormone replacement if she's having hot flashes, night sweats, mood swings, sleep disturbances, you know, all these other symptoms. There's like 30-some symptoms that can happen with perimenopause and menopause— vaginal dryness, painful sex, joint pain. And but again, individualized care. And that's what I do in my practice. I do a lot of preventative testing, a ton, but I also offer hormone replacement to majority of the patients.

Yeah, I mean, this is really functional medicine approach. It's just personalized care. It's looking deeply at your biology. It's understanding the risk factors and modifying those. It's working to help your overall health. I think we didn't talk a lot about the microbiome here, but I think it's a big factor in hormone metabolism, particularly cancer and overall hormone metabolism for women. So, there's a lot of things that can be done if you know what's going on. And I think most people don't have that information. And your, your work, your practice really is, is such a gift because you're actually helping people to understand that these are not just things they have to suffer from. And, you know, I, I wrote this article years ago, it was about PMS, and it was like 75% of women have some version of PMS or premenstrual syndrome. And I'm like, is, is this just a design flaw? Or is something else going on here? To me, it doesn't make any sense that our biology was designed to make women suffer the way they do and that these are things that are modifiable risk factors that we can change.

I mean, my daughter's at Stanford, Dilara. She's a senior and her project is on PMDD, gut microbiome.

Yeah, amazing.

Wearables for PMDD. I mean, these all have underlying risk factors.

PMDD is like a severe form of PMS. It's premenstrual dysphoric disorder, which means you're like, it's— you get temporarily insane for the last 2 weeks of your cycle.

Yeah. It's so sad for these girls. And again, it affects 3 to 5% of women. No one diagnoses them. No one. And I say they destroy every relationship during those 2 weeks, and then they spend the other 2 weeks going back and cleaning up, and then here comes again. And they start thinking, and it's so traumatic. These 10 days before their period is so traumatic to them that eventually it causes chronic anxiety and depression. Yeah. Um, and no one addresses this. They have a higher suicide rate. They— it affects their work, it affects their relationships. And again, it's— the list goes on. I mean, I can sit here until tomorrow and talk to you about every condition that women get dismissed. That's why, again, I started this podcast by saying women, A, don't have access, but even for women who have access, they're still being dismissed. They're still being told they're crazy.

They may have access to certain types of doctors, but not other types of doctors. And you have to think out of the box. And we didn't learn any of this in medical school.

No, none of it.

And yet the science is there. Like, the science, the data is there. It's just hard to change paradigms. It's hard to change the way people think or practice. And it's also hard for doctors to focus on things that they're not trained with, which is lifestyle or prevention.

But look at all the labs you do with Function Health, right? How much time would that take for a doctor in the office to explain all that to the patient? Yeah. Doctors don't have time. They have 10 minutes with the patient. A women's health exam right now, everything I told you I do and more, because I haven't talked about colonoscopy, bone density, Cardiovascular, all of it that I do, it takes 45 minutes.

Yeah, it's a long time.

You know what patients get? A Pap smear, a bimanual exam, maybe a prescription for birth control if the patient's sexually active, maybe an STD check, and maybe a breast exam. And if they're 40, they get a mammogram and off they go. That's not well woman. That's dismissal.

That's not comprehensive care.

No, this is nothing. It shouldn't even— I don't even want to call it It's standard of care because that shouldn't be standard of care.

Unfortunately it is though.

It is.

Yeah. Well, thank you so much for your work, what you do. Where can people learn more about you, your work, and, and how to calculate their lifetime breast cancer risk?

You know what? I started my, uh, SheMD podcast with my partner, Mary Alice Haney, about 2 years ago, and it exploded because we really talk about women's health. We take every topic in women's health, we cover it. We go in details of it, and from prescriptions to what they ask, we make women become their own health advocate. The only way to advocate for yourself in this healthcare system is to be educated about that condition, and that's exactly what we do. So I say go find me on shmdpodcast. I have all the information there. I have the

over-the-counter podcast.com.

Shmdpodcast.com. I also have ovii.com for anyone with metabolic dysfunction, anyone struggling, needing hormone balance, metabolic— struggling with metabolic dysfunction. It's a great platform. It has a calculator for PMOS, and we have the most amazing supplement. Thank you for having me.

Thank you, and thank you for your work. Thank you for not dying and helping us learn a little about this.

I love that. Make sure you add the lifetime risk calculator for all your patients, and make sure you're screening for endometriosis in all women.

We'll work on that. We'll work on that. Thank you. Thank you so much.

Hey, everybody, it's Dr. Mark here. I'm so excited to share that my new book is officially available for preorder today. After more than 30 years of practicing medicine and caring for tens of thousands of patients, I've written the book that brings everything together that I've learned about helping people get healthy and stay healthy as they age. It's called 100. What to Do Today to Live 100 Healthy Years is a whole body guide to living 100 healthy years. It's grounded in a new understanding of how our bodies work. It's the new map of the body. And inside, I walk you through the 7 core systems that drive your health, from your gut and hormones to how your cells make energy, and help you understand the signals your body's been sending you all along. Now, a lot of what's in the book, I learned the hard way through my own body. When I got sick, the medicine that I trained in did not have any of the answers I needed. So I had to go looking for them myself. And that search became my life's work. This book brings together decades of my learning from my patients, from the scientific research and scouring that, from the things I got wrong and the things I had to rethink along the way. I don't want you to have to struggle the way I did to find those answers. So much of our health is shaped by what happens outside your doctor's office. And I want you to feel confident knowing how to care for yourself every day. I put so much of myself into this book, and I'm really excited to finally share it with you. It's really my life's work. It's my capstone of my career that I put everything I know. It's finally available for order today. Preorder everywhere books are sold. Go get a copy. Please support me. And this is my life's work, so I think you're going to love it.