Avoiding the Emergency Room in Midlife with Dr. Alex Jabourian

Today I've got Dr. Jabourian, and this is going to be an interesting topic here because he is a trained physician in emergency medicine. And I wanted to have him on today because the worst day of many people's lives, the worst day of many people's lives when they end up in the emergency room, life or death, things have gone in a really bad area. Surprisingly, a lot of it can be prevented. And I'm talking specifically about midlife, middle age. And unless you're 11 to 200, most of you listeners here, you are in my age range. I'm almost 51 at the time of this recording. And this is important because a high rate of people that end up in the emergency room with the worst day of their life, things could have been prevented. So I really was excited to interview him today. So thank you so much for being here, Dr. Jaborian. Thank you.

Entirely my pleasure.

So let's take us back first, because I want to get to know you a little bit better. What got you into emergency medicine? Because my cortisol spikes just thinking about that.

Right.

Tell me, tell me about that.

It's definitely appeals to, like, a very specific type of person. But I got into medicine initially because I've done sports my entire life, and that kind of piqued my interest as far as human physiology goes, and I kind of pursued that. But emergency medicine is very unique in the sense that you got. You get to see a little bit of everything. You're not a specialist in any one thing, but you're pretty well versed in just about everything. We get to do procedures in the emergency department. We had to manage chronic conditions as well as acute issues and the prevalence of metabolic issues that I was seeing in the emergency department, which was landing a lot of my patients in the emergency department. You mentioned worst day of their life. It truly is the worst day of their life. They're having heart attack, stroke, or, you know, a million other possible presentations. A lot of that can be prevented with lifestyle modification, which is what kind of drew me to Mary Health, because that's essentially what we emphasize with Mari Cal. We implement. Yeah, go ahead.

Yeah, yeah, I'm going to talk about that in a minute because I want to really get into, like, what people can do to prevent, but talk to me about. So, you know, before we started recording, you mentioned that there's. There's a theme of, like, you're a little bit of an adrenaline junkie, so you wanted to do. Do emergency medicine so you could basically get in there quickly, navigate and figure out and react. But I would imagine it was quite surprising to you to say, to see, gosh, these are not the majority of, like there was a saw accident or, or this. But these are really interesting metabolic things. Can you. First of all, let's run me down sort of like, what was the theme? Like, what were the main things that you saw, especially when you people were coming and losing a loved one? Like, the main things. And this is close to my heart, by the way, because my dad died in an emergency room, you know, of a heart attack at age 49.

Yeah, I mean, it's sadly and unfortunately we see that quite often. We see, I mean, patients of varying ages as young as 30 years old to 60s, 70s and beyond, presenting with chest pain is an extremely common presentation. And chest pain may be anxiety. Right. It might be acid reflux or it might be because all of their arteries are clogged, causing ischemia of their heart and, and essentially killing off the heart tissue, which is a heart attack to myocardial infarction. We see that quite often. We see strokes very often. Again, that's often because blood vessels are blocked. A lot of these things and atherosclerosis in general are preventable. There is genetic component, obviously, but there's still a lot of things that we can do to mitigate that risk.

Okay, so when, first of all, let me ask this question. Especially stroke and heart attacks, I know that's super common. How does somebody know when. Okay, it's emergency room time or I need to suck it up. It might just be heartburn or it might just be this. And I think there's this, this attitude of I should just suck it up. For most people, they don't wanna believe it. So can you talk us through a little bit about, like, what's the warning of, like, no, this is urgent. You've gotta get to an emergency room. Versus this is, you know, I need to suck it up.

Yeah, I mean, it's really. The short answer is really hard to tell if you. Now, I'd caution if you have cardiac risk factors, if you have diabetes, if you have high blood pressure, high cholesterol, and you're having chest pain that needs to be evaluated because it's going to be impossible for you to know if this is something serious or not. And sometimes it's difficult for us to discern as well until we get our labs done, until we get our EKG done. But in the absence of all of those risk factors, in an otherwise young and healthy person, it's less likely that it's cardiac etiology, it's less likely it's a heart attack, more likely something else. But again, if you're concerned enough, if the symptoms persist long enough, if they're severe enough, come in and get checked. That's the only way to know for sure.

So as a doctor, I mean, because there's a lot of people pleasers out there or the people that say, I want to feel. I want to feel tough. I don't. I don't want to. Maybe it's in my head. What do you want them to know from you? Because you're seeing this, you're seeing people that should have come in earlier or that. I think some people are scared that the doctor's gonna go, why are you here? Like, you don't need to be here. Does that. Is that a realistic fear? Like, talk to us a little bit about that.

Who cares? If you get a doctor that says that, then that's probably not a doctor that you want to see. But regardless, whether a doctor says that or not, they're still going to take care of you. I like to think that I'm very, you know, positive in that matter, but that's what we do as emergency medicine physicians. We get to see everything and we get to treat all kinds of different ailments. And that's what I'm here to do. So you, a patient should never feel like they're bothersome to a physician. If you're there, there's. You probably felt that there was a necessity for you to be there, and that justifies you being there, even if your workup comes out completely unremarkable, which I hope it does. But if you're concerned enough, that justifies you being in the emergency department to get evaluated.

Got it. Okay. Just kind of a random question here before I get into some. Some meat of like, what optimal health is and what we should be testing for and those things. So we know. Is there any difference in your opinion when someone goes to an urgent care or an emergency room? Is there one that's preferred? Can you talk to us about that a little bit?

It depends on. There's a few differences, but it really depends on the type of facility. There are some urgent cares that have a lot of. They essentially function as, like, freestanding emergency departments. That's actually fairly common in Texas. We get freestanding emergency departments that have all the capabilities of full er, except they're not attached to the rest of the hospital. So if you have to be admitted, you'd have to be transferred elsewhere, and that's really the only difference. But most urgent cares are really equipped to handle like coughs, colds and minor procedures. Like if you need some stitches or if you have an infection that needs antibiotics or something like that. They're very good at handling that. If you're having crushing chest pain, if you're having one sided weakness or numbness or slurred speech or something like that, Urgent care is not the appropriate place to be. You need to be in the error.

Good to know, Good to know. Because I think people think urgent care is easier. But I hear what you're saying here. So go to the ER instead. Go to the er. Okay, talk to me about what people should be testing for because what I just picked up from you was that when I said is something urgent or not, you actually went back first to, well, if you have markers for things, we've got to take those seriously. So can you talk to me about like what should people be testing for? For? And why do so many doctors talk us out of testing? Like to me, I think optimal health and testing and numbers versus like traditional care, like what people are recommending. Can you talk to us about that? Like you being an emergency room doctor and seeing things being preventable. What are you testing for? What are you telling your wife to test for? What are you telling your loved ones to test for?

I, I recommend across the board everyone getting checked for signs of metabolic derangement, metabolic disorders. So that's checking your hemoglobin A1C, that's checking your fasting insulin, that's checking your lipid profile. In addition to that, I generally will recommend, and this is what we kind of prioritize, in addition to the metabolic issues is hormone optimization. And I generally will recommend someone has a rough idea of how their hormones are, especially if they're symptomatic in any way. So in addition to prioritizing their health, which is what we're going to get with those metrics that we talked about, we could also prioritize performance, which is where hormones come into play there. It's a little bit nuanced. Obviously your metabolic health can affect your hormones and vice versa, but that's why it's important to check everything.

No, I want to break this down a little bit more because some people don't even know what these things mean. So like when you say metabolic disorder, can you tell people that have never heard of that, like, what does that mean? What does that affect?

Yeah, so that's basically your ability to manage your, your sugar levels. That's your, the Amount of lipoprotein or cholesterol in circulation. These things are good markers to tell us how much at risk you are of developing cardiovascular disease. So that's like the heart attacks and strokes that we talked about.

You know, this is interesting because a lot of people put metabolic health, like they'll say, they think Aon C, they go right to type to diabetes or insulin sensitivity. But you're saying that actually affects heart too, not just diabetes. Can you explain that a little bit more? Yeah, I mean, I think people go for heart, they think cholesterol and high blood pressure. But honestly, you're saying that it all kind of works together.

It does, yeah. I mean, so metabolic syndrome is the constellation of all of these things. Metabolic syndrome. And up to 30% of the US population has metabolic syndrome.

30%.

30%. Wow. It's huge. And that's basically the constellation of increased waist circumference, glucose dysregulation. So that would be something like diabetes or pre diabetes, increased triglycerides, low hdl, which are a couple markers we can talk about when it comes to your lab work. Those are all symptoms of metabolic syndrome.

So really all the markers for diabetes and insulin sensitivity and the stuff for heart disease, they really all go together for metabolic. This is, this is interesting because I don't think people think about it that way. Think of it as one or the other.

Nope. All of these can potentially affect the way your, your, your blood vessel health overall. Which is what? Atherosclerosis is the development of plaques and inflammation of your blood vessel lining. That's what's going to affect blood flow to your vital organs like your heart and to your brain. All of these can affect that. That's why it's important to kind of tackle this from every different angle.

So when you say, and this might be completely under unrelated, but I want to hear about this too. You said it can also go to your brain. I'm imagining that, that it has something to do with why type 3 diabetes, otherwise known as dementia. Is that a thing? Is that accurate?

Yeah. So we tend to see with when patients have diabetes, long standing diabetes, really elevated fasting insulin levels, really elevated A1Cs, which are A couple of the lab tests that we check for diabetes. We also tend to see some Alzheimer's and dementia development. There's a lot more that kind of plays into that. There's genotypic testing like checking specific genes that may increase your risk of developing that at an earlier age, which is something that Merrick Health will check for as well, but we tend to see with patients who have poor metabolic health, an increased incidence of something like Alzheimer's dementia.

Now, does this. The poor metabolic health, like, if someone's listening and they're not, they're younger. Is this important to know? Younger? Is this something that hits us in our 40s and 50s? Like, what. Is there a specific age that you're. Like, this is serious. You've got to be testing for this. And is there anyone that shouldn't be testing for these things?

The sooner is better, especially if you have family history that's significant for heart disease. Like you mentioned, your father passed away at 49. I would be a lot more aggressive had you told me that, and I. I saw you in your 20s and 30s, we'd be testing stuff a lot sooner because this stuff takes years and decades to develop. If you have increased LDL right now, which is one of the lab tests that will check on your lipid panel, that tells me that you're at increased cardiovascular risk. You may not have any plaques in your blood vessels now, but if that continues uncontrolled 20 years from now, you may have plaques in your blood vessels. So when you're in your 40s and 50s is when this manifests as you potentially having a heart attack, but it's something that you could have prevented had you done some intervention in your 20s.

Yeah. So I want to share this, too, as long as we're talking on that topic. So, yes, I have all this in my family history, and my dad did die young. And. And in addition to that, I've all my grandparents, either heart disease or cancer, type 2 diabetes, across the board, like autoimmune in my family, all the things. So I had all the life things. I am neurotic, for lack of a better way of getting lab testing regularly, and I genetically do have a lower hdl, higher ldl. However, it's my only marker, and I believe it's because of lifestyle. So I've had all the heart scans. I check everything every 90 days. I'm really on top of it. And I have no issues at almost 51 as far as planning plaque or whatever. So just because somebody has a marker, I'm assuming you agree. Tom, if you don't, doesn't mean it's doomsday for you. By having the marker, you make other adjustments so other things don't become a problem, so you, you know, so you're fine. So my dad, for instance, he had extremely high triglycerides. I have basically no triglycerides. I Have no issue there. So just because you have high cholesterol genetically or something there doesn't mean a doomsday. It means we've got to monitor other things so we don't raise other risk factors.

I completely agree. I wouldn't chase one particular number. It's. You have to kind of look at it the bigger picture.

Okay, so let's talk about that a little more, because this is actually scary for me, especially working with so many women in fat loss. A lot of times people will come to me and say, okay, I had my regular checkup, and I. They. They always scream for cholesterol. They don't necessarily scream for everything else. They always scream cholesterol. They said, my cholesterol is high, and it's not. Sometimes I hear the number, it's not even that high. And they put me on cholesterol medicine. So to me, and I'm not a doctor, so that's why I'm running this by you. I'm hearing you have one indicator, one risk factor, and instead of digging to figure out where's that coming from, are there other issues? We're just attacking the number, the symptom. We're not doing anything to address the problem and what created it. Help me with that, because a lot of people listening that that's what's going on. They just had high cholesterol. They're on Lipitor now. Now their muscles are sore from that, and they haven't addressed anything else.

Yeah, I think this comes back to lifestyle modification. That. That should be your foundation before any kind of supplementation or any kind of pharmacologic treatment, anything that I would prescribe for a pat. We always have a discussion of lifestyle modification. That includes nutrition. That includes optimizing your sleep, your exercise regimen, managing your stress. That is by itself can, barring from some genetic abnormality, obviously can, for most patients, control all of these metrics that we're talking about. As far as blood work goes, that might be enough. And you may not need any pharmacologic treatments. That's where I start. Now, it really. I mentioned not chasing a particular number, but the numbers are helpful. So if a number is insanely high, that patient may benefit from pharmacologic treatment from the start in addition to nutritional changes or dietary habit changes or exercise changes. So sometimes we do this simultaneously.

Got it.

But it's very much an individualized approach.

Okay.

Yeah. That's how. That's how I would go about it.

Talk to me. And I'm gonna get into hormones in a Minute. But I want to first understand about optimal levels of things versus traditional. Why. Why do doctors vary so much on this? Like, why can I go to a regular internist or doctor and they're telling me I've got normal numbers where I'll go through testing with like, Merrick or, you know, a naturopathic MD or a functional medicine doctor, and they seem to have different ranges. Where does that come from? And how do we know what to follow?

I think a lot of that is. I mean, obviously it's scientifically backed, but we tend to see a lot more improvements in health and performance with narrower ranges of labs. If you look at LabCorp, which will, which Merrick Health will typically use LabCorp to draw blood work, and that's where we report our results. Their ranges are huge for everything. So sometimes a patient can be at the upper range of normal for LabCorp, but they can be way off the chart as far as what's optimal and what would likely reduce their risk of cardiovascular disease the most or would optimize their hormones best. So that's why our ranges are a little bit different than what you would see with typical lab like LabCorp Quest or some of the others.

Wow. Okay, so, so why. But is this something like in medical school? I mean, where does this even come from? Like, with knowing the numbers? Like, why do some doctors vary so differently on like the optimal ranges versus regular? Like, where is that? Where does that. Where is that originating?

I think some of it is based off what's in the research. Um, so if they've used wider ranges in like, journals articles, for example, then that's likely what some doctors are citing. But some of the neuro research will use a lot more narrow ranges, and we tend to see some improvements at specific numbers as opposed to the typical ranges that have been studied for some time. In addition to that, some doctors, it may just come down to experience. I mean, like, if I look at the numbers in the emergency department specific labs, that's very much different than what I'm looking at when I'm working for Maric Health, where we're trying to. To optimize health and performance. It's just. It's different. If I didn't have this experience with Merrick Health, I may not have these narrow ranges where I will typically refer patients to specific treatments and protocols based off lab numbers alone. So it may come down to just not having that experience of dealing with the upper limit of health and performance optimization.

Okay, let's talk about hormones, because this is a hot topic and I want to express first, I don't love that so many women especially go right to hormones for problems. And let me explain, like, I'm under the belief that. That we need to be testing and first be. We need to be testing from a place of. We've already taken care of ourselves nutritionally and movement wise and hydration wise first. Because I think what happens, especially in midlife, we go to, I'm fatigued, I'm tired, something's off. It be my hormones before we're actually like, are we cleaning up our diet? Are we moving our body? Are we doing that first? And then we can test for four levels there. Can you help shed some light on that? Is that accurate? Am I wrong there? And I'm willing to be wrong there. And what. What are the things that we should be testing for in midlife?

Yeah, no, I agree with you. Again, that's foundational. That's the lifestyle modifications come first. Now, with hormones and women's physiology in particular, there's a little bit more fluctuation week to week, obviously. And we can kind of go into just briefly with the menstrual Cycle is typically 28 days. Typically split into the first 14 days are follicular phase. Second 14 days are the luteal phase. And we tend to see some fluctuations of hormones throughout that cycle. So that it's those fluctuations alone. Some patients may be very sensitive to the effects of those changes and they might feel symptomatic as a result. But this is very much an individualized thing where some patients may not feel any difference at all. Where I. So typically, what we'll see before we get into particular numbers, because it's important when we're checking lab markers to know specifically which time during the menstrual cycle, we're doing the lab work because that's going to affect the way we interpret results.

Okay.

But during the follicular phase, we'll see increases in fsh, follicle stimulating hormone that prompts the maturation of follicles. Then we tend to see increases in estrogen. By about day 14, we'll see a spike in luteinizing hormone, which stimulates that follicle to release an egg. At that point, if that egg is not fertilized, we tend to see a sharp decline in luteinizing hormone. And during that second 14 days, that follicle becomes a corpus luteum. We start to see increases in progesterone, we start to see increases in estrogen again. And by the end of the cycle, we'll tend to See decreases in all of these hormones. So that last week or last few days of the cycle is when we'll typically see symptoms of PMS or hunger.

Too, as estrogen's dropping and all that. You're getting really hungry, ravenous. You might eat a whole box of something.

Yep. And not to mention, we tend to see a little bit more anxiety, mood swings. Depression is a big one.

Oh, yeah. My husband will talk to you about the mid swing situation, I'm sure.

So some. A lot of that is because of fluctuations of hormones, and that varies from person to person on how much, how severe those symptoms can be. Okay. So in that regard, hormones can cause a lot of the presenting symptoms, like fatigue, but you have to dial in everything else first before you contribute everything to hormones. Okay, and that comes back to what you were saying earlier.

What about the women that are in perimenopause? So things are not maybe even. Or they're in menopause, active menopause, or they pass. Like, how does that shift? And then how important is. Is that testing at that point?

It becomes very important, particularly pre menopause and post menopause. Well, because especially postmenopause can really dictate our treatment. But even in the perimenopausal phase, there are some things that we recommend as far as treatment goes, depending on levels and severity of symptoms, that can really alleviate those symptoms. It can really provide some relief. Something like micronized progesterone, for example, is something that will routinely give for patients that can really alleviate some of the symptoms that they're feeling at the latter part of their menstrual cycle. Or if they're in that perimenopause phase, they may feel those symptoms a little bit more constantly. And so it can be very beneficial in that regard.

Okay. Now there's some things that can go wrong with hormones too. So I just want to address it and I'll share something personal and I want to hear from you. So I want to share that. Before I really understood the importance of going deep on hormone testing, I had my general ob GYN test my hormones. This is years ago, so it wasn't like me understanding what should be tested. And just because of my age, he says, you're not in optimal levels of testosterone. So I at that point did bioidentical small levels of testosterone. And what ended up happening to me is, next thing you know, I became estrogen dominant. So then it was like, I need to add progesterone. And then I had a whole bunch of things that Happened. Okay. Because of that. And it wasn't until I started really dialing in my lab testing I realized, which I didn't understand before, that different hormones can go down different pathways in your body. So for me, for example, and this has happened to a lot of women, I wasn't getting optimal testing done. So what was happening is the testosterone was converting to estradiol, which is not amazing, which made me then estrogen dominant, which now I'm adding progesterone. So you're. I'm adding too many cooks in the kitchen, if you will.

Yeah.

To fix something that should have never been fixed, where if you are getting optimal testing, you can really understand what. What's going on. And because of that, I've really moved to getting tested every 90 days because of that. So talk to us a little bit about what can go wrong with hormones when not done testing. We're not doing testing correctly.

Yeah. So hormones are. Are really never my first option as far as treatment goes. It's really especially something like testosterone or especially something like estradiol, whether it's bioidentical or not. We tend to avoid use unless you're postmenopausal and your symptoms are very severe. And your numbers, you need it. But that's why it's really important to check your numbers. And a single lab test may not be sufficient. So we offer blood work, obviously, through Mary Kelth. Well, and we can talk about specifically what we're looking for as far as hormones. But beyond that, there's something called a Dutch test, and I know you're familiar with that. So it stands for dried urine testing for comprehensive hormones. And this gives you a lot more data, a lot more information, basically breaks down how your body's handling those specific hormones, what metabolites they're being broken down to. In addition to that, you're doing, I believe, it's five urine samples throughout the day. So you're getting a. You know, like chronologically, you're seeing some fluctuation there. Specifically for cortisol, that becomes extremely important because that's something where if you have it elevated in the morning, that's expected, but if it's elevated throughout the entire day or chronically, that causes a lot of issues. So something like Dutch testing is extremely important, and it could be a useful tool in addition to the blood work that we typically do.

So I do all of it. I do the urine test, too. But can you. For someone that doesn't understand, why do we want to do blood and urine?

Yeah. So it's It's a little bit. Blood test is basically checking what like the hormone level at that particular time in the bloodstream. But that does not tell you how your body is. Kind of what your body does with that hormone, which is the metabolites that we're testing with. Dutch testing basically tells you. You mentioned testosterone is being converted through aromatase to estradiol, correct?

Yeah.

Some of that information we can gather through something like Dutch testing where you're actually testing the function of those enzymes like 5 alpha reductase or aromatase and determining that really helps you fine tune treatment. Because if I gave you testosterone, had we done the Dutch testing and realized that you're very likely to convert testosterone testron, we could have predicted what would have happened afterwards.

That's how mine. That's how we found out. Based on blood, it looked normal. Based on urine, I had a big problem there. Okay. What about saliva testing? How do you feel about that? Do you recommend that? Is that something you include? I know that is easily contaminated, so I have concerns about that. But talk to me about that one.

That's not typically something that I would order and I wouldn't rely on it. I think between the blood tests and Dutch testing, I think we get all the information that we need. Okay. It's useful for something like DHE sulfate in particular. But beyond that, I don't really feel that it's very useful.

Yeah. I'm certainly not a doctor. My, my doctor, my personal doctor had always recommended the saliva test for me. And I, I'm. I battle, I battle her with it. Like this is not. I don't like it. And I'll tell you, the last few times I've done it, it came back contaminated. Like both times it said that I had crazy high cortisol or testosterone when I wasn't doing taking testosterone and it didn't match the numbers of the blood or the urine and like extreme. So there's just a high contamination rate on that too. I don't know know why, but that's my, my experience with that.

I think it's convenience. It's a really easy test. Right. So I think that's primarily why they developed the test and why they still sometimes recommend a test. But I feel like we get much better metrics doing the blood and urine testing.

Got it. Okay. Okay. Talk to me about why Merrick Health. Because some people are like, well I should just go ask my doctor or I don't know, like why did you join with them and why do you think they're revolutionizing Things and, and just any information you can share with that about.

Yeah, so I, before I was a provider with Mary Health, I was a patient with Mary Health, and that's primarily through my frustration with going through the healthcare system. I have, I have health insurance, but it's sometimes very difficult to find a physician who's comfortable checking all of these metrics. We're just, we're. Unless you're an endocrinologist, you're not formally trained in checking hormone levels and you wouldn't necessarily know what to do with them unless you've kind of taken it upon yourself to educate yourself on these in particular.

Got it.

So Merrick Health, the way it works primarily is once your, your most bang for your buck is using the full service, which is essentially getting a comprehensive lab panel. And that puts you in touch with a patient care coordinator, which is a member of our team who's extremely knowledgeable. And they will basically break down your lab results for you on paper and, you know, verbally. And then they will recommend certain over the counter treatments or lifestyle modifications, dietary changes and exercise protocols that may be beneficial. After that, you get in touch with a physician if necessary. And then we can kind of break things down a little bit further in a lot more detail. And if necessary, we could obviously prescribe medications to treat various ailments. But it's comprehensive, it covers everything.

And I like that it puts it back in the care of the charge of the patient. Like you're not relying on your general checkup to do all this for you. You're taking control and saying, I need to understand these numbers and get results.

Yeah, absolutely.

Okay. For those of you listening, I moved all my personal testing over to Americal. So I test myself. I might be aggressive, but I'm almost 51 and I have a huge family history. I test things every 90 days. For me, that's what I do. I, that's what I'm a fan of not telling you. You have to do that. But what I did, because so many people were asking me, like, well, okay, well, Natalie, what do you specifically test for? What do you recommend? And I'm basing this not from just me, it's from the many doctors I've worked with and the conversations I've had. And so this is specifically for you. If you're listening and you're a woman in your 40s, 50s, 60s and beyond, that's who. I'm specifically putting this list together for you. But if you go to marekhealth.com so it's M A R E K health.com forward slash Natalie Jill. So my name. Because that'll take you to the exact listing. You can check it out yourself. You can order test from the comfort of your own home and know what you're doing there. And Merrick was awesome and gave me even a discount for you if you use the coupon code Natalie Jill. So it'll even save you some money, which is always a good thing. But that's how you can yourself go get tested. Anything else you want to share with people that you want especially? I mean, I know guys, I got you on too. So some of you are on for like, can you just touch on that a little bit for the guys real quick? And I'm gonna go back to the women. What do guys need to know?

It all the same. Obviously, we don't get as much fluctuation with hormones as, as, you know, women do throughout their cycle. Our testosterone levels are a little bit. They can fluctuate throughout the day, but we tend to see larger changes over a longer period of time. But everything else applies. It's. It's all the lifestyle modifications first and then obviously we're very comfortable with hormone management if necessary.

So good? Yeah, so good. Okay, ladies, women, get your stuff tested. Get yourself don't end up in the emergency room. Live longer, healthier you're going to. Your spouses will thank you. When your hormones are balanced, all the things, let's get rid of the metabolic problems. You can do all this through testing. Thank you so much for being here today, Dr. Jaborian. This was super helpful. I hope none of my listeners see you in the emergency room, and I hope many of them get to work with you through Merrick Health and their testing.

I. It's entirely my pleasure. Thank you for having me. And I'm looking forward to seeing a lot of your clients with Merrick Health. So if you ever need anything, please let me know.