207. Cynthia Thurlow: On Women’s Health, Intermittent Fasting, Protein Intake & Hormone Therapy

One thing that I think I probably have not overemphasized enough is how critically important a woman's menstrual cycle is. It is as important as blood pressure, pulse, temperature. If a woman loses her menstrual cycle and she's not pregnant, guess what? That is a sign that her body is under too much stress.

I noticed that women did not fit the common mold when they were menstruating. Some of the worst endocrine disasters that I ever saw were women that ate in a very, very narrow feeding window.

We have been part of a culture that has really sent a very damaging message to women. That thin is what we want to attain.

If you don't feed the body, it starts to survive on less and less food, and it does that by slowing down the metabolism.

Fasting is one of many strategies, and I think that most of us eat too frequently, and most of us eat too much of the wrong food.

There's an intermediary between the food that we're consuming and the body's ability to utilize that food, and that has to do with our gut microbiome.

The way that we need to think about it is that everything affects the health gut, and everything about the gut impacts every other choice that we make.

I'd love to go through your three broad categories. Menstruating, perimenopause, menopausal, and a lot of women listening to this podcast are like, I want to go down the intermittent fasting journey. How do I decide if I'm a candidate or not?

What women do not understand is that.

Ultimate you. Hey, guys, welcome back to the Ultimate Human podcast. I'm your host, human biologist Gary Brecka, where we go down the road of everything, anti aging, biohacking, longevity, and everything in between. And today, we're coming to you live from London. I have a very, very special guest. Women, you are going to want to pay attention to this podcast. Welcome to the podcast, Dr. Cynthia Thurlow.

Oh, thank you. I'm a nurse practitioner, not a doctor practitioner.

Sorry.

I want to make sure I make that clear.

Well, you can actually practice independently in a lot of sites. Florida.

I actually can in Virginia.

Supervision, Nevada. Same thing.

Yeah, I mean, independent practice is an important part of advanced practice nursing for sure.

And, you know, you guys do all the work anyway, so. Sorry, docs, but. So they should have the right to practice independently. You know, there's. There's a common theme that I find, and it's. It. It holds so true in your case. That runs through a lot of my Podcast guests. I find that some of the most impactful, passionate, purpose driven people are in that position because they solved the problem in their life. And before the podcast, and I've seen this before, and watching you on number of media channels, you were a nurse practitioner, arbor nurse practitioner, and you were in the emergency room. You were wired to adrenaline and the adrenaline rush until there was a time that you started to struggle metabolically, probably also emotionally, physically, and you pulled up the bootstraps and said, there's something different for me. Can you just tell my audience about that journey?

Yeah, so I worked in clinical cardiology for over 16 years. Prior to that, I was an ER and trauma nurse. So yeah, I am definitely an adrenaline junkie. And I think as my kids were starting to get a little bit older, and by that I mean elementary school age, I had one with severe life threatening food allergies. And it really got me zeroed in on nutrition and how nutrition plays a role in our health. And you know, that then evolved into wanting to focus more on lifestyle as medicine, which as you can imagine, in traditional allopathic medicine, this is what, how many years ago? 20 years ago. Oh, gosh.

Lifestyle medicine, 20 years ago. That's quackery.

No, no, they thought I was, they were like, oh, we have this nurse practitioner and she likes to talk about food. And I would say my peers who are about my age were always very supportive. The older docs were generally, they thought I was crazy and so they would support me and facilitate this interest. But over time, I was getting increasingly disillusioned with the concept of writing prescriptions for lifestyle related issues. And I got to a point where I was telling my husband I was having a harder and harder time. I would go to work and I would tow the party line and I would do my job and excelled at my job. But concurrently I was also in the throes of perimenopause. But I didn't fully appreciate that until I was weight loss resistant. I wasn't sleeping well, I had brain fog, I was anxious. I'd never been anxious before in my life, even probably bordering on a bit of depression just out of frustration, like all the things I tell women to do aren't working for me and what's going on. And so I think it was both a catalyst and also the realization that I felt like I could make a larger impact by leaving traditional allopathic medicine and, and my own journey of figuring out for myself what are the things I need to change about my lifestyle, which wasn't too Bad to begin with. But what are the things I need to do differently in perimenopause to ensure that I remain metabolically healthy, that I ensure I have enough energy to take care of my kids, that I can contribute to my community in a way that feels affirmed and valued. And so for me, it was really this massive leap of faith on April 1, 2016, when I left traditional allopathic medicine and I told my husband, who thought I was having a midlife crisis.

I guess he was already. He was going through perimenopause with you.

Trust me, he was like, I think you're having a midlife crisis. And he said, I give you two years. Two years. And then you have to figure this out. And so within that two years, I had landed my first TED Talk. And the irony is to be totally transparent, almost instantaneously I was attracting one on one clients and, and created group programs. It was very clear to me that many women felt the same way that I did. Their needs were not being addressed in a proactive manner. They didn't feel seen or heard. They were generally, and I use this term very delicately. But when a woman comes to a provider and says, I've gained weight and their response is your X age and this is just the way things are.

Yes, that's.

That for me was so unbelievably frustrating. Cause I said f that that's not the way. That's not gonna be what I'm going to accept for the next 30, 40, 50 years of my life. And so that was a powerful impetus. But that then evolved into a couple TEDx talks, a podcast, a platform where it was very affirming that my husband was like, okay, this isn't a hobby. You really are making an impact.

Yeah.

And so, you know, for me it's, you know, life kind of comes full circle and I'm like, I can't imagine my life any different than the way it is right now. Like, I was meant to be an entrepreneur. I just didn't realize it.

Right.

And so.

And you had two TedX talks. What was that first talk about?

Perimenopause. And in 2018 was talking about it in 2018. I was so embarrassed. I got on that stage and I was telling someone this today. I remember being so embarrassed to talk about perimenopause because women are shamed into not aging, were told to shut up and not talk about what's happening with our bodies, emotionally, spiritually, physically. And I got up on a stage and I was like, if I didn't Know what was gonna happen. How could I expect any of my patients to know? And I trained at arguably one of the best medical institutions in the country. And I'm like, if I. It wasn't part of my education as a clinician, how could I expect my patients to know what they should be anticipating? And so it was incredibly freeing to do that. And as an introvert, absolutely terrifying.

Yeah. You know, I think that, you know, women's health has always been treated the same as all health. Right. So men's health, women's health, you know, we go down the road of intermittent fasting. One size fits all. Cold, plunging, one size fits all diet, one size fits all. You should be on carnivore because your husband's on carnivore. Your husband eats in a narrow feeding window. You should eat in a narrow feeding window. You know, he's weight training. You should weight train. It's these, these one size fits all. Especially when talk about women are not applicable in many cases. And I found this out the hard way. I had a similar trajectory. I was in the mortality space, decided to end that career and get into the functional medicine space. I'm only a human biologist, so I'm actually not licensed to practice medicine, but we started a functional medicine clinic and in, in treated hundreds of thousands of patients and had some amazing practitioners. But I noticed that women did not fit the common mold, and they didn't fit the mold at different times of their life when they were menstruating. Some of the worst endocrine disasters that I ever saw were women that ate in a very narrow feeding window. Like, their husband was really into CrossFit, so then they got into CrossFit and that was fine. But then while they were doing CrossFit, everyone was intermittent fasting. And then sort of the shorter the window, the better the window. And some of these young women that were eating in these four hour windows or six hour windows, their cortisol, their cycles were just a follicular stimulating hormone, luteinizing hormone. And so they were actually gaining weight, eating in a narrow feeding window. Their husband's jacked, it's pissing them off. And then their sleep would go out the window. So I'd love it if we would talk, maybe open the conversation about with intermittent fasting, because I love what I've seen you say on other media outlets. And I think it's so good for women to hear this and get some relief that, yeah, maybe, maybe all intermittent fasting is not good for every woman.

Yeah, I mean, I would say Bio individuality absolutely rules. And when I say this, whether it's peak fertile years 35 and under, perimenopause 35 to 50 or menopause 51 and older, I would say that each individual really has to look at it from their own lens. So a 24 year old who is lean and athletic has no business doing a lot of intermittent fasting. Now, if someone is 24, they're obese, they have polycystic ovarian syndrome, or they're type 2 diabetic, probably some degree of time restricted feeding is probably a good idea for a variety of reasons. But one thing that I think I probably have not overemphasized enough is how critically important a woman's menstrual cycle is. It is as important as blood pressure, pulse, temperature and respirations. And if a woman loses her menstrual cycle and she's not pregnant, guess what? That is a sign that her body is under too much stress. And so when a woman says to me, I start, started fasting and I then skipped a couple cycles, I'm like, time out, stop what you're doing. And I would be the first person to say that. I think a lot of women benefit from some degree of digestive rest. And men too, frankly. That could be 12 or 13 hours of not eating. That is not formal fasting. But I think in many instances that can be very beneficial. The other side of intermittent fasting is that there's a time in a woman's cycle when she should fast and there's a time when she should not. And what I find is in my perimenopause and menopause patients, because they are so frustrated with weight loss resistance, because they are frustrated with body composition changes, and we can certainly unpack this, they think of a little bit of fasting is good, more is better. So whether it's the CrossFit, the fasting, the carbohydrate restriction, the overemphasis of protein and protein is very important. The overemphasis on hormetic stressors, whether it's infrared sauna, whether it's cold plunging, whether it's high intensity interval training, it is taking things to an extreme. In a body that is conditioned to respond to stressors, we don't need as much stress to create hormesis in our bodies. And so when I'm talking about intermittent fasting, I always say, I feel like I have to apologize because I didn't emphasize this enough before. And so now I feel like I want to undo perhaps some of the unclear messaging, fasting is one of many strategies. It is not the only strategy. And I think that most of us eat too frequently and most of us eat too much of the wrong food. So if you change the food frequency and it could be that you still eat three meals a day and you're doing it in 12 hour windows, that's great. That is far better than what the average American is doing. And so I think the messaging is important to actually talk about women, how attuned our bodies are to stressors, how we probably don't need as much stress on our bodies as men can tolerate. And I would say menopausal women, there's also a special group there because we're not dealing with the hormonal fluctuations that we once dealt with, you know, day to day, week to week throughout a menstrual cycle.

Yeah, you know, I noticed that in a lot of our young menstruating females, so menstrual years for fertility years, that we would notice that as they narrowed the window, their thyroid metabolism would drop almost universally across the board. I'm sure there were some outliers that I don't remember, but, you know, so nothing's more frustrating to a young woman than restricting her eating. And when she's restricted eating, very good, you know, working out in a fasted state, going hammer down at orange theory, 55 minutes, three, you know, five days a week, and then retaining water. Yep, it looks like fat. While their spouse is just love and life.

Yep.

And one of the things that we would notice is, you know, when, when the hemoglobin A1C that, that, that three month average of blood sugar would get very, very low. 4.8, 4.9, 5.0. Meaning they're spending a lot of their time hypoglycemic. That almost universally you would see the thyroid say, hey, let's slow down the metabolism. We're not getting enough nutrients, so let's slow down the metabolism. It's almost like what happened on the Biggest Loser. If you ever watch the documentary afterwards.

Did it was fascinating, disturbing.

Very disturbing.

Very disturbing. Very fascinating.

I mean the transformations were shocking. But nearly every single one of these contestants not only gained back the weight that they lost, they ballooned to catastrophic new weights. And when you peel back the layers of the onion, it's hard to outsmart your human physiology. Right. I mean, a lot of our biology is there to protect us. So if you don't feed the body, it starts to survive on less and less food. And it does that by Slowing down the metabolism.

Well, look at all these patients that have whittled themselves down to one meal a day. And this is, I don't ever get as much hate as I do when I talk about one meal a day. So Omad, how many women have said to me the way I lost 50, 60, 100 pounds is that I now eat one meal a day. And I remind them, how much protein are you eating in that very narrow window? And they'll tell me, and I talk about why body composition is so important. I was like, yes, you might be a size X, Y or Z, however, you probably have lost quite a bit of muscle. Muscle is our metabolic currency. You've lost your metabolic currency and now you're eating 600 or 700 calories a day and you're wondering why you've either plateaued or you're stuck. And so I think that you're exhausted.

And your sleep's off.

Yeah. And I anger people when I say you are not eating enough food. And so whether it's getting people into this kind of reverse diet, which I think can be controversial, but saying, okay, we're going to add 100 additional calories of protein a day and we're going to monitor body composition and we want you to be lifting weights. But more often than not, we have been part of a culture that has really sent a very damaging message to women that thin is what we want to attain, the thinner the better, often at the expense of losing muscle mass.

And we know how GLP1s don't help.

That if you're not lifting and eating enough protein. Absolutely, that is a huge piece of it. So I always say like the body composition, it's like let's really dial in on what's your fat free mass. How much muscle mass do you have on your body? Because more often than not, and I'm constantly working on this myself, very transparently I am thin, but I am constantly trying to fine tune, like adding a little bit of muscle. It is a hell of a lot harder at this stage of life. Even with hormone replacement therapy and with lifting, it is still challenging.

If you want protein to build lean muscle but without the caloric impact or need to cut, you need perfect amino, it's pure essential amino acids, the building blocks of proteins in a precise form and ratio that allows for near 100% utilization in building lean muscle and no caloric impact. So we build protein and six times as much as whey, but without the excess body fat we normally get during bulking. This is the new era of protein supplementation and it's real. If you want to build lean muscle without having to cut, you need perfect amino. Now let's get back to the ultimate human podcast. Now how about peptides? Where do you fall on peptides? I do too, because I've seen that, you know, a lot of women do very well on these growth hormone peptides, not growth hormone. I think that would be very dangerous. But, but the growth hormone peptides, the GHRPs and GHRHs, CGC 1295, iPomorelin, Sermorelin, Tessamorelin, and we have experienced in our clinic, you know, women seem to do very well on those. Also helps their circadian cycle if they take it the proper time at night. But I'd love to, so I'd love to unpack that, but I'd love to sort of go through your three broad categories of women. You know, menstruating, perimenopause, menopausal. And you know, a lot of women listening to this podcast are like, well, I, I'm, I want to go down the intermittent fasting journey. How do I decide if I'm a candidate or not?

Yeah, I mean, I would say kind of broadly. If you're not sleeping, if you're not managing your stress and that's not five minutes of meditation once a day, if you're just not, if you have a disordered relationship with food already and this is just going to feed the machine. You know, I see a lot of that on social media as well. It's people that have latent eating disorders like anorexia and they'll just say, oh, I'm just intermittent fasting. Yeah, no, you just don't eat right now. You're not intermittent fasting, you just don't eat. So I think when I'm, when I'm looking at the appropriateness, it's like, how is your lifestyle to begin with? And then how can we tweak and kind of determine whether or not this is right for you? Again, if you are very lean and exercise a lot, I would actually argue that you can put yourself in. It's called the red. It's relative energy deficiency. And this is where a lot of very athletic women or very active women can just have themselves in a caloric deficit in perpetuity and that can be harmful. So that's number one. I think it's being honest with yourself, like where do you fit in? And I am certainly not an athlete, I don't pretend to be an athlete, but I am an active middle aged person. I Think really looking at can you sleep through the night? Do you fall asleep and stay asleep? Because sleep is foundational. And if a woman, irrespective of what age she is, tells me I don't sleep well, I'm like, that is the first thing we have to address. Because sometimes when you start reducing the amount of food you're eating, that can worsen the sleep piece. And especially because of the cortisol response or other things can be cortisol response. Some people are much more sensitive to carbohydrate intake. And so at the very beginning of my intermittent fasting journey, I was very much into carbohydrate cycling. Never was I ketogenic transparently, but I think many people took from that that I'm anti carb. I'm not anti carb, I just like smart carbs like let's eat the non processed varieties. I think carbohydrate can be very important for many people. And so really kind of dialing in the sleep piece, addressing the stress, like don't add in fasting. If you're going through a divorce, you lost your job, you're in the midst of a big move, someone in your family's sick, that is not the time to add this additional stressor. So really kind of looking at, you know, what is your feeding or the amount like the hours in which you are eating now and how could we compress that and maybe see some improvement? And even it could be from you have a 12 hour feeding window, maybe we compress it to 10.

Yeah.

Can you get enough protein into that feeding window? That is always my question. Now if the answer is I cannot get at least 100 grams of protein in a day, then the answer is your, your, your feeding window is way too compressed.

Right.

And so I like to work with numbers. I'm very quantitative. And so I will sometimes say, you know, if you have two meals a day and you get 100 grams of protein in, that's not bad.

Right?

There's probably some room for improvement.

Two meals and 100 grams of protein, that's, that's 50, that's pretty good. I mean it's a lot of chicken.

But most women, what they're doing is when I ask them to track their macros because I'm like, let's build awareness like Chronometer. I have no affiliation with them, but it's just an easy way to track macros. How much protein are you eating? More often than not, it's 50 grams total.

Wow.

And again, we're talking about not Only are we undergoing. It's men go through andropause, women go through menopause, but we go through this entire, whether it's our thyroid, it's our adrenals, every single endocrine organ takes a hit during this middle age transition into menopause. And so helping people understand we have to recalibrate everything. You know, my 17 year old and my 20 year old can probably sneeze and stimulate muscle protein synthesis. Like truly, their bodies are so anabolic right now we know as we're getting older we need more protein, not less, sometimes in some instances three or four times as much as we did when we were younger. So at a bare minimum, building awareness around what does 30 grams of protein look like? Because you need at least that to stimulate muscle protein synthesis. And I would actually argue you need more. So really helping them build awareness because what I find is, oh my God, that's so much protein, I can't eat that. Well, maybe you go from 4 ounces to 5 ounces of fish, steak, chicken, et cetera. We're not looking to stuff you, but we want you to build awareness around what is a proper portion of protein look like.

That's, you know, why, you know, often recommend that women will take the essential amino acids too. Because I think a lot of the protein equivalent, we always equate protein to muscle, which is true, but, but it's not just muscle. It's your natural killer cells. It's your connective tissue. It's collagen, elastin, fibrin. I mean, there's so many structures that are built from these amino acids because that protein is broke into amino acids and then those amino acids go out and build all kinds of structures, not the least of which is muscle, but certainly not the only thing. So we, I think women, you know, it's like creatine. And I want to unpack that too. You know, I've always considered creatine a bodybuilding supplement. And, and it was, I mean, the 90s, it was a big rage, you know, like BCAAs, which I consider to be sugar water, you know, like just really expensive lemonade. But, you know, I think it's important to highlight that, you know, protein is going to become amino acids, which are the building blocks of not just muscle, but so many other structures in the body. Which is why when you're protein deficient, you can start to see this myriad.

Of issues starting to become very catabolic. Like I always like to use the example and sometimes my podcast community is like, yes, Cynthia, We've heard this story, but I use it to kind of demonstrate. In 2019, I spent 13 days in the hospital and I was incredibly.

That was an appendicitis, right? I think I.

That was. Yeah, that was that fun 13 day journey of every complication.

So it must have burst.

I mean, so what's interesting was my husband and I accompanied my husband on a business trip. First time I'd been able to do that. We get home, I'm like, damn, I got food poisoning. So I'm up, I'm vomiting, I have diarrhea, I feel terrible. The next day, my husband's like, you don't look so good. And I was like, I don't feel good. And so I spent the whole day in bed and touched base with my internist who I was friends with. And she was like, you know, you need to go to the hospital because you still aren't feeling good. Right. Like, I want to make sure that's clicking in your brain.

Yeah.

And so by the time I get to the er, it was the worst abdominal pain I'd ever had. And I was like. I looked at my husband and there's something called. I've heard people describe impending sense of doom. And so when a patient says to you, I think I'm going to die, you take that really seriously. And I looked at him and I said, if they don't figure out what's wrong with me, I'm going to die. Like, I just knew it without a question because I could not get comfortable. It was worse than labor pain. And they kind of poo pooed me because I didn't look particularly sick. And then they ran blood work and the ER doctor came in and said, something's wrong. You've got a massive white count. So my massive white count, over 20,000, I mean, way high, sent me for an emergency CAT scan. And they were like, I couldn't even put my arms above my head. I was in so much pain. I had an idea of what might been wrong, but I had such diffuse abdominal pain. And they were like, well, you have a ruptured appendix and you have ruptured appendix. Ruptured appendix, and you have pan colitis, which means the entire length of my colon was inflamed and angry. And the surgeon came in immediately and said, I want to take you to surgery tonight. We're going to take your appendix and we're going to take your colon. And I said, no, time out, I need my colon. She's like, no, you don't. I was like, Yeah, I do. I'm just asking you to give me 24 hours. 24 hours. And if my white count goes down, my fever goes down. So that started a 13 day hospitalization.

Wow. They did go in and fix the appendix, right?

Oh, no, this story gets better.

I was going to say, because a ruptured appendix is septic emergency.

What they've learned, though, is that if they can manage it, because right now your appendix ruptures and then it spills all this putrid content into your peritoneum, which is a bad thing, because you can get peritonitis, which is life threatening. And so on day two, I developed small bowel obstruction. I think on day five, the surgeon was. I mean, they were really worried. I had all these specialists coming in to see me. They were like, cynthia, we don't know what's going on. Your fever's going up. I've got an enchi tube down. I mean, I'm really sick. And I had a. What I would describe as. I've had patients tell me where they have experiences, where they perceive that either God or spirit comes to them and gives you an option, you know, do you want to fight or do you not want to fight? And I was like, I've got two young kids at home. I can't not be there for them. But it turned out I had retroperitoneal abscesses. So I had to go interventional radio.

All of these things have. That's just pain on top of pain.

So interventional radiology came in and put tubes in to drain them. And then I developed a fistula. So I had a communication between the appendix and my cecum. And so I was so sick that I was discharged to home 15 pounds lighter. So you want to talk about catabolic? My muscle, I had no muscle and I was too sick to take my appendix out. So my Appendix came out six weeks after my hospitalization, 10 days after I did that second TED talk.

But now it's already ruptured.

It's ruptured, but it was encapsulated.

Ah, so it actually didn't spread? It did, but you had an infection, but just. It was localized.

Yep.

And IV antibiotics, the whole IV antifungals.

I mean, it just decimated my gut. So when I say to people, if you don't actively work at building muscle, your body will actually break down the muscle you have, and that's catabolism. And so that's what happened to me. So I jokingly say I lost 15 pounds of muscle, six years ago. And it'll probably take me 10 years to put that muscle back on, if at all.

Wow.

So I talk about, I don't say this to sound extremist or to sound, you know, like I'm trying to garner sympathy because I processed it all, but I think it, you know, protein is so important. And I, to your point about essential aminos? My younger son got mono in January, and he bodybuilds and he's as mixed martial arts. He's very athletic. That kid did not lose muscle during mono, even though he did not live for four months because he was using essential aminos every single day.

Huge fan of that, and I'm so glad you said that. You know, I take them every day. I take all nine of the essential amino acids because a lot of the protein that we put in our body, like collagen, is just not a complete protein.

Correct.

You can't even build muscle from collagen.

Hair, skin, and nails. It's great for that.

Yeah. Hair, skin, and nails, it's good for, but so are all the essential amino acids. You have the same amino acid profile to build that as you would need to build muscle. And you have the extra benefit of building muscle and, and not maybe turning into sugar or, or fat. So I, I, I think Dr. Gabrielle Lyon, she, if you're watching this, Dr. Lyon, she's, she's fully on board with your. Oh, she's a good friend.

She's a good friend.

She's a good friend of mine, too. She's, she's amazing. And she's been the champion, I think, at least the female champion of, you know, you need to get more protein, you need to get more amino acids, and you need to be weight training if you want to live a long time, start lifting weights.

Do you want to. The first conversation I ever had with her, which was in 2020, we both spoke on a panel together, and we connected instantaneously. And during the course of our first few conversations, she said, you're probably not eating enough protein. And I was like, a what? And, you know, I give her full credit for opening up my mind and impressing upon me how critically important it is to consume adequate protein and why we need more with aging and not less. Because I think a lot of people are like, oh, I'm thin or my body composition looks fine. If you are not doing body composition readings at least quarterly or at least twice a year. So at least two to four times a year. You don't know. You don't know because I just had Mine done and my VO2 max. And dang, it's like, you know, it's like every time we're just trying to fine tune, like, okay, still got to put on a little bit more muscle.

Yeah, so. So protein for sure. But let's start unpacking creatine because I think it's. It's making headway now, and I think it's returning to a core supplement for a lot of women. I put the vast majority of my female clients that are over 40 on. On creatine, HCL or monohydrate. Sometimes that they bloat on HCL, but very rarely do they do that. Where do you fall on creatine? I think the science is, is. Is pretty astounding, actually. Higher levels than I would have ever thought, like 20 milligrams to or 20 grams to cross the blood brain barrier and really bathe the brain. But where do you fall?

Yeah, I'm creatine. I think that it's a foundational supplement. So creatine monohydrate not just for muscle strength, but also for neurocognitive benefits. And there's evolving research about bone health. Anywhere from 8 to, you know, 10 grams a day or more. I think the quality is important. So I always say that the research is really around creatine monohydrate. But the quality is certainly important because what I hear from a lot of people, including family members, oh, when I take creatine monohydrate, I get bloated. You don't wanna buy the crap from China. You wanna buy Korea pure. It has to be licensed through, I believe I'm saying this properly. We license ours through Germany and it costs a little bit more. But it's actually as the Germans are. They're very organized, methodical about the way that they manufacture products. But I think what's exciting and evolving is the research around brain health. And you're right, you do need more to get across the blood brain barrier. Blood brain barrier is designed to be protective. What's ironic is most of us don't have a healthy blood brain barrier because most of us also have concurrent leaky gut. And it's always like, leaky gut, leaky brain. So you have these permeable membranes that are designed to protect us, but helping people understand. Like when I am traveling, like right now we're in London, I'm doing 20 grams of creatine monohydrate daily.

Wow.

I start three days before you take.

It in powder or liquid?

Liquid. I do it in powder.

Okay.

And I just dump it into my water along with my electrolytes and I'm good to go.

Yeah.

But I will do that preceding three days preceding travel, especially with time zone changes. And three days after, and I've come to find that I sleep better. We know that creatine monohydrate can be very helpful for brain support if you are jet lagged, but also if you just have a crappy night of sleep. And occasionally that even happens to those of us who pride ourselves on having good night's sleep. So I think creatine monohydrate for both men and women is very important. But I think the science is evolving. And what's interesting, because I have some patients that are still getting menstrual cycles. And it's like if you look at a broad section, there are time in a woman's cycle where we need more and less creatine. And so we have 70, 80% less endogenous creatine stores than men do. So that's why supplementation is so beneficial. But if you look at kind of a cross section of women, there's times in the cycle when we can actually benefit from more. That's why I think taking it daily is, is very helpful. Sometimes people will say, I'm not lifting today, I don't need creatine.

Right.

And I always say there's so many other reasons other than muscle strength.

I agree.

I think it's really, really helpful. And it's an. It's one of those easy, like straightforward, you know, it doesn't have to be fancy. I think it can be an easy thing you can mix into a smoothie or you can just consume in water. Good quality creatine will dissolve pretty easily in water.

I totally agree with you. You know, you bring up the gut. I remember Dr. Perlmutter, David Perlmutter wrote a book. And I forget if it was Gut Brain connection or Grain Brain came first. But I read both of his books and the first one was so eye opening to me. I mean, he was.

He's brilliant.

Yeah, he's very brilliant. And he's a Naples resident. I was living in Naples at the time. We ran in the same sort of friendship circles. And I read. Can I forget which one I read first? It was either Grain Brain or Gut Brain Connection that, that he wrote first and was the first time that someone had so eloquently articulated the connection between the gut and the brain. He called it the second brain. And he, he also talked a lot about menopause and perimenopause. And how we're not actually eating, which was the way that he phrased it, was so amazing. We don't eat to feed ourselves, we eat to feed our gut bacteria. That's the only reason why we eat. Then our gut bacteria eat to feed us.

Yeah.

So there's an intermediary between the food that we're consuming and the body's ability to utilize that food. And that has to do with our gut microbiota. And I think even in, you know, gastrointestinal GI circles, you know, they didn't really put much emphasis, there was emphasis on pathology. Oh, you have diverticulitis, you have ulcerative colitis, you have Crohn's disease, you have irritable bowel syndrome, which is sort of just a name for a collection of symptoms. And those were widely considered to be things that were just happening to you. Right. Not happening within you. And talk about the importance of, you know, gut health for women. And, you know, I think so many things are foundationally rooted in the gut. You know, you talked about for your first time. And this is very common for women. You know, here you are this, this, er, nurse practitioner and you're experiencing anxiety and anxiousness for the first time. And that's frightening because you've gone your whole life not being this anxious or having to deal with anxiety and all of a sudden you just have these sensations of impending doom out of nowhere. And, you know, your spouse or your family members are throwing the typical lines at you. There's no reason for you to feel that way. There's nothing for you to be afraid of. Why do you choose to act like this? And the truth is, it's not a choice, you know, and you've heard those. So let me tell you about something that's been a total game changer for my sleep and my stress levels. BiOptimizer's magnesium breakthrough. Here's the thing. Most people don't know. Regular magnesium supplements only give you one or two forms, but your body actually needs seven different forms to function properly. That's why you might be taking magnesium and still feel tired or stressed or having trouble sleeping. Magnesium Breakthrough is the only supplement that combines all seven bioavailable forms in just a single capsule. Within just a few days, I noticed I was falling asleep faster, staying asleep longer and waking up actually more refreshed. Plus, my post workout muscle recovery has been incredible. If you're ready to finally get the deep restorative sleep you deserve and feel more relaxed during the day, head to bioptimizers.com and use the code ultimate to save on magnesium breakthrough. Trust me, your body will thank you. Now let's get back to the ultimate human podcast. So talk about the, you know, the importance of gut health. And for women that are starting this journey, like how do they evaluate it? Like where do they start? There's so much information out there on gut health.

No, you bring up so many good points. I mean I think that what we now understand about the gut microbiome, so let's unpack. That is exponentially more than any of us were trained with. So when I trained back in the 90s and early 2000s, we weren't talking about the oral microbiome, the vaginal microbiome, the gut microbiome, the lung microbiome. None of that was discussed. I think now we're understanding how critically important our health is, interrelationship with these microbiomes. So we have trillions of bacteria and protozoa and fungi that are all beneficial to us in the microbiome in our guts. And it intersects not just with neurotransmitter production, it intersects with how well we can fight off infections, whether or not we make things like short chain fatty acids, which are critically important, how well we feed the colonocytes, which are the cells in the colon that are so important for crav creating these short chain fatty acids. It's also very important for understanding that there are axes throughout the body. So it's the gut lung axis, the gut bone axis, there's the gut ovarian axis, there's the gut gonadal axis, and it goes on and on and on. So nearly every organ system in the body is intricately connected to the microbiome. And whether it's a function of our modern day lifestyles where we are super stressed out, we are not supporting our circadian biology. We are eating ultra processed food like substances we eat too frequently, we drink too much, you know, we over exercise, we don't exercise, we have fulfilling relationships. We don't have fulfilling relationships. The role of the evolving research on adverse childhood events and the effects on the gut, it's the way that we need to think about it, is that everything affects the gut and everything about the gut impacts every other choice that we make. So those bacteria, fungi, et cetera, influence how our moods are, they influence the way we perceive the world, they influence our ability to break down different types of macronutrients, they influence how well our body fights infections. And for women in particular, we know estrogen plays this incredible role in immune system Functioning. And so it is involved as well as progesterone with how easily do we have a leaky gut? And so I think for a lot of individuals navigating that perimenopause to menopause transition, there's a lot that goes on that makes us much more susceptible to opportunistic infections, that diversity changes. And the irony is before a woman goes into puberty, a young girl and young boy's microbiomes are very similar. The influence of sex hormones. And really now we're trying to think of them not just as sex hormones, but estrogen, progesterone, testosterone, change the microbiomes of young women and young men in puberty. And then the irony is when a woman goes into menopause, our microbiomes start to resemble men's again.

Wow.

That's how vastly evolved they are. So life comes full circle. And so when we're having these kinds of conversations, I think it is so helpful for people to understand that although we cannot see all these microorganisms, their health is as important as our health.

And so trillions of them.

Yeah. Yes. And there's literally nothing that we do in our day to day lives. Like right now, my circadian biology is shifted a bit because I'm on a different time zone, as is yours, all of your team. And so the things and the decisions that we make when we are in this state of hormetic stress shift the microbiome. So it's like those bacteria are trying to shift to accommodate all of these changes. And it's, it's fascinating to me, you know, depending on what time you eat, depending on what time you wake up, I mean, those bacteria are constantly shifting in response to our lifestyle.

So you know what's interesting? I have a tip that I tell people when they travel and this has been a game changer for me and I've never heard anybody else talk about it. And that's, you know, on the East Coast, I'm roughly in bed around 10 o', clock, 10 30, and I'm roughly up by 5, 5 30, maybe 6 o'. Clock. So that's the time frame that I'm normally sleeping and I'm pretty consistent about that. I find that if I travel and I eat during my normal sleeping window, so we're five hours ahead here, I would normally be up by six o' clock in the morning. So but if I eat at what would be 1am or 2am my time or midnight my time, that wrecks my, it makes my jet lag 5x worse. And, but if I just preserve that eating window, meaning I don't eat when I would normally be sleeping. So if I'm Normally awake at 6am then here I wouldn't start eating before 11am Just that little shift has made a huge difference in my ability to adapt to time zone changes and I'm pretty militant about that. And now that you're bringing up a good point, it's very likely tied to, I'm going to refer to it as a term that probably doesn't exist, but the circadian rhythm of my gut microbiome.

It'S a real thing.

So at least I'm feeding them at the same time.

They like consistency, the body thrives.

That's why you've been good to me.

Yeah, well, and the other thing is when you're jet lagged, you dysregulate your glucose, which means your fasting glucose goes up. It means, you know, you have this down toward effect. And, and this is when, when people are jet lagged or sleep deprived, you generally don't make good food choices, you generally will probably drink more alcohol, you probably won't exercise. And so like today as an example, you know, my friend went and did a bunch of stuff. She's like, if you want to go shopping, I was like, nope, I want to walk around outside with no sunglasses. Yeah, I did that for an hour and a half. I was like, it's really important input for sunlight on my retina. No sunglasses, I have light eyes. Sometimes that can be challenging in the middle of the day. But I did that for 30, for an hour and a half. I grabbed some lunch while I was out, I grabbed a salad, went back to my hotel room and I felt instantaneously better just with that one input. End to your point about when I ate, maybe it was a little earlier than I normally would eat, but it was roughly around the time that I might be breaking my fast, traditionally in the morning. And so I think that as much as we can stay kind of attuned, depending, I mean if obviously our in Asia would be more challenging but you know, being five hours ahead, it's, it's a little more conceivable that I can get away with that.

Yeah, go to Australia next week. So I'm like worried about it because I'm like they're exactly, I think they're fucking 14 hours. So I'm going to have to do some math on that one.

Yes, you're going to be a little bit upside down. For sure. For sure.

Yeah. And it's Only five days. So it's not enough to jump on that time zone and just deal with it and get through it and change. So. So I'm going to do my best to preserve my feeding window. But of all the things I've done, and I do the same thing you're talking about doing, getting sunlight into my eyes. First thing in the mornings. I drag an ass a little bit when we woke up here and I just put my jogging shorts on and my running shoes and I did, did like a fast walk and then I worked into a nice light jog. It's kind of hard to jog in London because I'm always about to get hit by a bus coming from the wrong direction.

And that's. I was going to say I have to catch myself. And actually the cab driver, when I took my cab over, he was like, ma', am, you're going to get hit, you need to be on the opposite side of the road.

Have you seen the look right and look left arrows that are at every one of the crosswalks? They must have wiped out a lot of the Yankees because. Because as soon as you come to the crosswalk, there's these big white letters that say look left or look right. Yeah, because we're just not used to seeing traffic.

Yeah, no. So I tend to stop and wait. And if there are other people that are clearly have inhabitants of London, I let them move first.

Yeah, you're like, just do what they do. Yep, I do the same thing in New York, assimilate. So, you know, we know the, the importance of the gut microbiome. But so for women that are suffering from those conditions that we know are. Have a strong link to the gut microbiome. You know, one of the things we didn't talk about was the immune system, which about 70% of it is sitting right there. I think that's because that's where all the action is. But they're having anxiousness or anxiety or, you know, the classic gas, bloating, diarrhea, constipation, irritability, cramping. They can't seem to link it to the food that they're eating. They're on a relatively clean diet. I've had a lot of female clients like this. Where do they start on the gut microbiome bandwagon? They're like, okay, I want to pay attention to the gut. I want to test it somehow and I want to fix it or feed it.

Yeah. I mean, so I think it's very bio individual. So when I'll give you an example, when a patient says to me, I don't tolerate fiber, I'm like, then you really have some disruption in the microbiome. And remember I mentioned the story of my hospitalization? I couldn't eat a vegetable for almost 18 months.

Wow.

Because my gut had been so decimated, my microbiome, because I had all these antibiotics.

Oh, IV antibiotics are brutal.

So I think I was full carnivore for nine months. And my tell, and I'm watching my husband go through this right now. We may talk about his story, but my tell is that when a patient tells me I cannot tolerate fibrous foods of any capacity, I'm like, all right, we need to kind of of take 10 steps back. So therapeutically, I like to look at stool testing, and I do think that's important. If someone is. If we've done like a whole 30 and they're still having gas and bloating and diarrhea or constipation, I'm like, all right, Whole 30.

Stool. Stool test, yeah. Okay.

So Whole 30 is actually kind of a broad based elimination. It's gluten, grains, dairy, soy, alcohol, sugar. If we pull all those things out and they're still having symptoms, okay, maybe move on to food sensitivity testing.

Okay.

There are a lot of different stool tests that I like to work with, but I would say stool testing plus food sensitivity testing, and then getting really nuanced about do they have micronutrient deficiencies. If we're really kind of digging deeper, you know, oftentimes women need a personalized set of recommendations for them. So it could be, you know, maybe they don't have enough digestive fire. Maybe they have, you know, not enough hydrochloric acid to help break down their protein. Maybe their digestive enzymes, which we know as we get older, we just make less of them. It's kind of like everything else. It's like tires that are worn out on a car. So sometimes you have to change out the tires or maybe add some supplementation. So digestive fire issues that can contribute to gas and bloating, underlying food sensitivities that can contribute and that can be very bio individual. I think most women by the time they're in their 40s probably are not tolerating gluten, potentially grains and possibly dairy and certainly alcohol. People don't like to hear that because they like their fun foods. And I get it, right? People may find when they travel outside the United States, they can eat bread in Europe, but they can't eat bread at home.

So True. The folic acid, seed oils.

Yeah. Different type of dwarf wheat, which is what we have in the United States, which is less likely to spoil versus some of the artesian wheat sources they may use here. When I'm looking at it from a higher level perspective, it's like, are you eating standing up? Are you eating in your car? Are you eating on the go? Are you chronically stressed out? Are you not in a parasympathetic state? Like something that seems so simple. But most of us are not relaxed when we eat because we're rushing, we're eating off our kids plates, we're eating in the car. We don't eat healthy food. I mean there's a lot of things. So it's like really getting down to the nuance of that. Certainly when I was rounding on patients in the hospital, I was lucky if I got to go to the doctor's lounge to eat. That was unusual.

Most of the other nurses don't pee for 12 hours.

So what did I do? I was eating crappy protein bars and rounding because I needed to get through rounds and I needed to see the patients in the ICU and consults in the ER and wherever else we were seeing patients. And you know, we were an interdisciplinary team of providers. But now that I have the luxury of being able to slow down a little bit, this is when I'll say to women, okay, what are you doing when you eat? So that's another piece that can contribute. And you know, it's also this loss of estrogen and progesterone can definitely impact how quickly we can move food through the digestive system. We know estrogen and progesterone both play a role. We know that when we are more prone to leaky gut, we are more prone to amplifying these food sensitivities. We know that we are more likely to be dealing with, you know, it could be a pathogenic, I see a lot of E. Coli, I see a lot of salmonella. Occasionally we see a lot of dysbiosis, which is an imbalance of beneficial to non beneficial bacteria in the gut. And so that's just a starting point for ground zero. But I find if women are open minded enough to do a little bit of testing, try some elimination diet, add in some digestive fire, and that's not a technical term, but that's just how I choose to explain it to patients so they understand like that is very personalized. I don't need to take hydrochloric acid, but I do take digestive enzymes. I need that for me personally.

Yep.

And then the other piece of it is, you know, what's your sleep like? If you're not sleeping, you are not going to make good food choices. When I don't sleep well, I do not crave chicken and broccoli. I'm going to crave. Even though I don't eat gluten, I'm going to crave, you know, chocolate. That's usually my vice in life. That's like my one that's nice.

Really such a bad one.

I mean, but, but it becomes one of those things. I'm like, why am I thinking about the chocolate? Oh, because I haven't slept well. That is definitely contributing. So I think there's a multi layered, you know, issue that can kind of be apparent. But those are kind of the broad level things that I start to consider that are contributory. And then again that loss of estrogen and progesterone. So women that are on HRT are generally having less bloating, gas, constipation, diarrhea.

Very true.

And to tie up the constipation piece, because I think it needs to be said constipation is not normal, full stop. If it's brand new, it needs to be evaluated. If you are someone who is a non public pooper, we have a lot of those in the world, they have their bathroom at home and they don't feel comfortable in an airport or a hotel room or at their loved one's home. They have to go at home so they will constipate themselves because they are not relaxed. I think a lot of people that have chronic constipation, some of it is psychological in the sense that their body doesn't feel safe. So whether it's a squatty potty setting aside time to go. But when a woman says to me, I poop two or three times a week, I'm like, that is a problem. Huge problem, huge issue. And especially what women don't realize is that we have this estrobolome in the gut and that is designed to help us process and recycle excess estrogen. And yes, you can be in an estrogen deficit and be recirculating estrogen that you're exposed to in your environment, personal care, products and food. And so helping people understand that strobalome is a very important facet of having a healthy digestive system, packaging up and processing estrogen. And how do we package it up and process it. Usually it is, you know, there's a. Dr. Carrie Jones always calls it a present. But there's a way that we can package it up and poop it out. And so if you're not pooping every day, and I have to just be blunt, that is not normal. We should be going at least once or twice a day.

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Well, I think, I think it depends on the patient because some people are like, before I even think about paying for testing. Let's do the basics. Do you need to set aside time? Do you need a squatty potty? Because we know it can lift the knees. That can make things easier. A lot of people are just chronically dehydrated and that's why they can't poop. I mean, it sounds silly, but our bowels will reabsorb water in the colon. And so when someone says to me, they have hard stool, they have pebbly stool, they have hemorrhoids, they really have to strain to go, that's a sign that it could be a hydration issue. Now, if this is brand new, you all of a sudden are constipated and it's problematic. That needs to be evaluated by a licensed medical provider because it could be another underlying issue. But in most instances, I would say things like Trafala, which is ayurvedic magnesium glycinate or biglycinate can be helpful. I think some people benefit from just doing some abdominal massaging. Not that you're sitting there for hours, but sometimes just moving like that. Yes. And that kind of clockwise direction can be very helpful. But I feel like I get really good results with Trafala magnesium. My other trick is usually to do, you know, raw salads can be helpful, but A tablespoon of fresh ground flax and a tablespoon of chia seeds together. Brilliant.

Wow. Tablespoon of chia seeds, Tablespoon of fresh ground flax. You put em in a blender?

You can put em in a blender.

And does it become oily?

No, the chia seeds don't need to be ground but the flax, you know, you wanna grind it down so it's not so kind of chalky you can put it in a smoothie and I mean a tablespoon isn't too much.

Right.

But I find for a lot of people like those are simple things. And then you know, if that doesn't work we go to aloe vera juice which doesn't taste great. Chlorophyll, I mean those kinds of things, you can kind of start amplifying it. I'm not a fan of resorting to stimulant laxatives if you're constipated.

Yeah, I agree with that.

I just think there's a lot that can be done and I find for most people those kinds of tips are life changing. Like I have women that will travel with, with, you know they, they put it all together, they have their chia and flax and they take their tablespoon out every day and they're like I don't care if I have to stick it in water. I just know this is what helps me stay regular. And I think that's, and, and it's, we've gotten conditioned to suppress our urge to go which is another thing. You know people like when my kids were little they would, you know, rush home from school because they refused to go to the bathroom at school. And like, you know, you're setting yourself if you complete, continue to suppress the urge to go. That in and of itself can be a problem.

Yeah, I would totally agree with that. And then there are the women that want to take a dive into their hormones, right into their cycling. And this is a wide open area. We gravitated from doing blood testing for hormones to using almost exclusively the Dutch test. And our clinic director was a, or is a board certified OB gyn. She was such a doctor Sarda shout out to you was a big fan of this Dutch test. I learned to read these easy on early on and I, I found that it was so much easier to get to the root cause of their hormone deficiency or hormone excess, their dominance by looking at the ratio of these hormones throughout this 24 hour period. It's 24 hour urine test. So where do you fall on. On hormone testing. Testing. Do you use the Dutch test? Do you like that one? Are there other ones that you like? And are you a fan of in menopause hormone therapy? Because I will just tell you anecdotally, it was life changing for my wife, Sage, and for me too. It's like we've been very open about.

It, you know, after.

Yeah, I was wrong a lot. Did a lot of apologizing for things I didn't do. But, you know, just as a human biologist, as she started, I started seeing these symptoms go. And she is lean, fit, you know, eats very clean, exercises with the trainer, you know, does all the things. And when all of a sudden the wheels started getting loose on the wagon, you know, and she was around that age, you know, late 40s, we took a deep dive. And I will tell you, life changing. What's happened to her? She had the first and shoulder. I mean, if it was a menopausal symptom, she had it the brain fog, sleep disruption, you know, mood imbalances. She would just. I would walk into the room and she would say, I am furious with you, but I know that I have no reason to be furious with you. You may just want to give me some space.

That would be the, the. The loss of estrogen irritability. Yeah, for sure.

And she's like, I don't even know why. And. And then things that were not catastrophic, she would think about it and it would just make her cry. And I was like, babe, this is not you.

Yeah.

And. And it was relatively rapid onset. But after the Dutch test and supplementing for those deficiencies, we cleared up a comp T gene mutation issue that she had. Mood, sleep, sleep energy workouts, mood swings. You know, I would say 90% result. And she's so much more comfortable in her body.

That's great.

But where do you fall on that for menopausal women, you know, getting on hormone therapy? Because there were some scary data out there early on. Most women don't know that the. The study that implicated hormone therapy and breast cancer unimplicated it later as they continued the study. And that one stigma of hormone therapy, breast cancer, you know, I think has a lot of women frightened to even start.

Yeah, no, no. I mean, we field only 5% of US women are on HRT. So there. That statistic is significant. So, number one, I like testing and I like a combination of blood testing, I do saliva testing, and I do use the Dutch Dutch specifically because I like for certain women, I want to know what's Your estrogen metabolism, like, how well are you breaking down these metabolites? I do like the Dutch for looking at distribution of cortisol over a 24 hour period of time. I think that's really valuable too.

Yeah, it shows you that.

Yep. And dhea, so I think those are certainly important. But I would say that I'm, I'm a combination. So I've always got my allopathic hat on as well as my functional hat to kind of decide what are the tests this patient needs us to run. Now, if someone is still in perimenopause, their hormones are all over the place, Right. And it becomes more challenging. Now, some women will say, I know if I look at an FSH or an amh, the anti mullerian hormone, I might have a sense of where I am on the trajectory of am I getting, am I knocking on the door of menopause or am I not? And so that can be helpful. But we do know that, that, you know, our estrogen as an example, is 20 to 30% higher in perimenopause than it is at any other time in our lives, which is why women have so many symptoms.

Right.

You know, this relative, and I hate the term estrogen dominance, but we have, our ovaries are making less progesterone. The adrenals are kind of stepping in to be a backup quarterback. And we have this relative estrogen dominance because we have 20 to 30% higher levels for a period of time. And then it drops off kind of like every day.

But that's when the water retention and shows up. And they're retaining water for no apparent reason. No change in diet, no change in lifestyle habits. I mean, that is super frustrating.

Yeah. Oh, totally, totally.

A woman just starts retaining water out of nowhere.

And I think some women are more sensitive to that because I think so too. Some people are just like, even with. And I am pro hormone replacement therapy, which I'll get to.

That's what I wanted to get.

But I think that, you know, progesterone in some women, like, it doesn't cause me any fluid retention. But when I was pregnant years ago, when I was put on progesterone in my first semester trimester, I recall, like, I was incredibly bloated, but it was probably more a function of the pregnancy than it was the progesterone. So I'll just go without saying that the study that you are referring to is the Women's Health Initiative that was published in 2002. So I was a baby nurse practitioner. And even though I was not prescribing hormones. I was in cardiology and I had patients coming into my office who were crying, who were upset, upset, who were devastated. They were taken off their hormones. Now, we have some good data from that study, but we also have a lot of information that was misinterpreted. You know, just to give kind of broad strokes. It was largely an older population, people that were more than 10 years into menopause. Many of them were former smokers, many of them were obese. Many of them had underlying hypertension, high blood pressure, you know, in some instances, probably not metabolically healthy. And they extrapolated that information. They were looking at progestin, so non bioidentical progesterone. They were also looking at conjugated equine estrogen, which is premarin. So they weren't looking at bioidentical hormones. And actually, you know, the research certainly suggests, if you pull all the research out of that study, we know that estrogen has some very protective effects for the breasts. There's a book called Estrogen matters written by an oncologist, Dr. Avrin Bleming, and Dr. Carol Taver, she's a researcher, excellent resource. That's usually what I recommend to people if they really want to understand what the whi did wrong again. Now things are coming full circle. We're talking more openly about the fact that these were not body identical or bioidentical hormones. They were extrapolating a lot of. We know that progestins are not particularly helpful for women in terms of there's no equivalency to body identical or bioidentical progesterone. Same thing with conjugated equine estrogen. You're getting like 40 different estrogen metabolites. It's not the same as estradiol, which is the predominant form of estrogen. Our bodies make up until menopause. So I am very pro hrt if that is the right choice. It is a shared decision making. What I find is people are still scared.

I agree.

They are worried that hormones equal cancer. And so we have to have those conversations. I'm like, listen, you're still going to get your mammogram, you're still going to get pelvic exams. This month is actually gynecologic cancer awareness month. And so there are five major gynecologic cancers. So I tell everyone that's why getting a pelvic is important, because, you know, unfortunately, ovarian cancer, there's very little signs that happen. But for most women it's important to get a exterior, to get your exterior hardware checked out by your GYN or your internist or whoever's doing that exam. So when we're talking about hormone replacement therapy, we're talking about progesterone, we're talking about estrogen, and in most instances, we're also talking about testosterone. I would actually argue that whether that's thyroid replacement, we're talking about DHEA for people who need it. Pregnenolone, which is so important for memory. Really, really important.

Just, it's a precursor for so many.

Downstream cortisols and very important for maintaining memory. So I, I tell everyone that's something that I, I check on my patients just to kind of see where we are. But I find for most women, if we're starting with a hormone, we're probably starting with oral progesterone. Oral progesterone. I sometimes will hear, well, my doctor said that my uterus was taken out, so I don't need progesterone. I'm like, no, no, no. These are not just sex hormones. They are hormones that nearly every receptor in the body uses. We have progesterone receptors on bone in our brains. It is so, so important. So generally, progesterone, because a byproduct of that is a neurosteroid allopregnanolone that is so important for sleep inducing. Sleep. Are there people that are sensitive, intolerant, or even allergic to progesterone? Yes, but most people do just fine, usually start with progesterone. Then I usually will move on to estrogen, then testosterone, if that's needed.

Yeah.

And I think that this is just my personal feeling. I am probably a little more conservative. I am not a pellet fan because I can be wildly unpredictable. I've had women who insist they know their testosterone levels are low because they went from feeling awesome to then they feel terrible. And it turns out their testosterone is three times what it should be.

Right.

And so, and you're stuck with it.

Very often if it's overdosed, you're stuck for that. And if you're underdosed, you might be stuck too. Yeah. If you're underdosed, you might be, might be stuck too. Yeah, I, I, you know, I think the sublinguals, we use a lot of something else patches, because if you make a dosing mistake or metabolism mistake, you just, you can, you can correct it. I'm glad to hear we're on the same page with that. I just, you know, I wanted to undistill some of the fear because I think, you know, it's, it's like the old Time magazine article on saturated fat. I mean, we're still trying to undo the war on saturated fat.

Well, and what's interesting is it goes, this is so cardiology and lipids were my like pet interest and passion for years. And I remind people the bio individuality piece is important and it's important to understand that what is happening with estrogen. So women will say to me, I'll give you an example, I am 55, I'm 45, I'm 60, whatever age they are, I don't need hormones. I feel great. And I would be the first person to say, and I respect that and I think I am all about women's right to choose with shared decision making. But what women do not understand is that as we are navigating this perimenopause to menopause transition, there is a lot of inflammation that is below the surface. And I'm going to give you one example. Estrogen is intricately tied into nitric oxide production. Nitric oxide is very important for the endothelial lining in our blood vessels. So as estrogen's going down, as we were making less nitric oxide, our blood vessels can't dilate and come back together and come back together the way they once did. It also sets up a lot of inflammatory pathways. And so women will say, I don't need estrogen. Yeah, you do. You know, the number one killer of women is heart disease, full stop. One in three women will die of atherosclerotic cardiovascular disease. So the things that I think about when I'm talking to a female patient about hormone replacement therapy is I just want you to understand what the research says about whether it's oral estradiol or a pack much. And we could argue that for certain people, maybe oral estradiol and very low dose might be better and more heart protective than a transdermal dose. But that's again very bio individual. But you start looking at how estrogen works mechanistically in the body. And so there's a class of drugs right now called PCSK9 inhibitors, Repatha. They're very expensive, but it's one of the few drugs that will drop lp.

It does drop lp. I didn't know there was a pharmaceutical solution.

So it's, it's unfortunate because it's super expensive and not everyone can afford it. And when I say it's like the kind of expensive, like thousands of dollars a month expensive, like most people can't afford that. And. And the traditional labs that are done for men and women, they look at a total cholesterol. They look at ldl, which used to be called bad cholesterol, and hdl, good cholesterol and triglycerides. So that's a standard lipid panel. We are still seeing providers that are only doing that and trying to. Trying to prescribe a statin.

Yes.

Based on that alone, just LDL if.

It'S above 99, statin.

And so if your LDL is high, it's probably a sign that another lipoprotein, apolipoprotein B, is probably high. And that is something we need to look at as well as lp. Why are they important? Because they are more impactful on our overall risk for developing heart disease. And I would argue most providers are not looking at these.

I would argue that too.

LP is genetic. Mine is high. I got it from both my parents. And that's why I know so much about PCSK9s. What's interesting is estrogen acts like a PCSK9 inhibitor.

Wow.

So for someone has a high LP, I would argue that estrogen replacement therapy is. Is critically important.

Wow.

And so when I'm talking about whether it's heart disease risk, bone health risk, dementia risks, it's just important. And those are like, the three big ones. But it also goes into, like, are you more likely to have leaky gut? Are you more likely to develop neurocognitive decline? Are you more likely to develop, you know, frailty issues? And so it really becomes this domino effect. So, yes, I am pro hrt.

Okay, good.

Always with the context of what is your own biological risks. And so for someone who is not metabolically healthy, maybe has high nat. Again, it's genetics. Like, you can't. Sometimes we can't fix genetics, but it's helpful to understand, like, what are your specific risks? So APOB LP needs to be drawn on everyone. And what's interesting is 20% of the population has a high LP. And if you're African American, it's 50%.

Wow.

And we know that most African Americans are not getting the kind of care they deserve to have. So I want to make sure I just say that in case you're listening. Get it checked. If it's low, great. If it's not low. And more often than not, we see those numbers going up. APOB LP go up in menopause, not as dramatically, probably in andropause. The other thing that I'll just tie into this, I'm going to get off the lipids thing. My lipid soapbox. Triglycerides. No, it's important because people don't talk about this.

So important.

Triglycerides. If your triglycerides are more than 70, you have work to do. I would argue that the traditional, you know, you should be less than 150 milligrams per deciliter. You're already dealing with some degree of insulin resistance.

Yes.

And not enough people are talking about this.

Yeah. And the insulin resistance ties to the triglyceride. People that eat the most sugar have the highest blood fat. It's not people that eat the most fat have the highest blood fat. And I think when you see triglyceride, you equate that to fat. So I reduce my saturated fat intake, which causes you to increase your carbohydrate intake and then it gets worse and it doesn't make sense to you. In fact, when I, when I was doing labs on Dana White and his triglycerides were critically elevated, I put him on a 10 week keto reset just for 10 weeks to bring his triglycerides down.

How high were they?

790.

And risk for pancreatitis fasted. And it's. If you look at the labs when they're drawn, they're very fatty.

Oh yeah, the, yeah, the. I'll never forget my, my daughter was a nurse that drew the labs on him. And you know, you lay the, the vials on the table, you wait 30 minutes to spin it. So she, she had him laying. It was in his office and she went around the corner where he couldn't see her and, and I could. And she was like, oh my God, Dad.

Yeah, dad.

And she inverted the bottom and it was already beginning to coagulate.

So someone like that, if you're over 500, they're at risk for pancreatitis.

Yeah. So he was right on that verge. But Cynthia, this is like amazing advice. You're amazing. I want to touch on two other things real quick. You out. Which I want to highlight. I'm going to put a link in the show notes so my listeners can hopefully get on a, a pre launch list for you. What's the title of your new book?

The Menopause Gut. So it's gonna, it's gonna die.

Showed me the COVID today too, and it's beautiful. So.

No, it's the menopause gut. Dive into all the things with the gut microbiome, all the things that change. And like I was mentioning earlier, when we go into menopause, how trauma impacts the microbiome, how a healthy gut impacts how well our bones stay healthy. I mean, it literally impacts every part of the body.

And for my listeners that want to know how to find you, where can they find you?

Probably easiest to go to my website, www.cynthiathurlow.com. you can access to my web, to my podcast, Everyday Wellness, and all my social media channels.

Okay, great. I'm going to make sure we put that in the show notes. And I wind down every podcast by asking all my guests the same question. Bears, there's no right or wrong answer to this question, but what does it mean to you to be an ultimate human?

You know, I think that the way that I would answer that, being an ultimate human is being like the ultimate example, not just to my family, but also my community. Because ultimately, I'm not saying I'm perfect, but I do endeavor to make sure that I'm living a virtuous, kind, thoughtful life and doing everything I can to live as healthfully as I possibly can. Because, you know, they talk about the marginal decade. I don't ever want that to be the case. So doing all the things I can now to forestall ever having to deal with that.

That's such a great answer. Well, I'd love to have you back when your book launches and talk about how. How that's going for you, and. And my audience is gonna eat that up. So thank you so much for coming on the Ultimate Hearing today.

Thanks for having me.

And as always, that's just science.