Hormone & Fertility Experts: We've Been Lied To About Women's Health! If This Happens, Call A Doctor

0:00If someone's menstrual cycle is

0:01irregular, should they be concerned?

0:03>> Yes.

0:03>> Yes. Yes. Yes. Your body is meant to

0:05work like clockwork.

0:06>> And our monthly cycle is so much more

0:09than getting ready to have a baby,

0:11especially when we're looking at

0:12exercise. And it's important to say if

0:14you don't have a period, it's very

0:17harmful to long-term health, brain

0:18health, mental health, low energy, mood,

0:20and libido. And I don't want the younger

0:23generations to have to go through the

0:24stuff that we've gone through. So, it's

0:26an important discussion that we need to

0:27have. We are joined by four leading

0:29female health experts from very

0:31different fields

0:32>> to have a crucial conversation about

0:33women's health. With over 80 years

0:35combined experience, they're sharing the

0:36truth about what every woman and every

0:38man needs to hear.

0:40>> We asked a thousand women to submit

0:41their questions ahead of this

0:42conversation. And I got so many

0:43questions around fertility,

0:45understanding hormones, PCOS, birth

0:47control pill, miscarriage.

0:48>> And I'll say this, Stephen, it's because

0:50we haven't had these discussions

0:51publicly. When we look at funding in

0:53women's health, it's horrible. like less

0:54than 1% is spent on women over 40.

0:57>> Women are living 20% more of our lives

1:00with chronic disease or mental health

1:01disorders. I mean 50% of patients with

1:03unexplained infertility have

1:05indometriosis. But yet it takes women 7

1:07to 10 years to get a diagnosis after

1:09symptoms start. But also there are

1:11things that we do that will inherently

1:12harm our fertility because we're not

1:14taught this and it predisposes you to

1:16many medical problems later in life.

1:18>> And patients will say but I have a

1:20really high pain tolerance like it's a

1:22badge. And so they gaslight themselves.

1:25And that's what we're all trying to

1:26fight here. But there are a lot of

1:27things we can do to deal with this.

1:29>> And then I want to talk about menopause.

1:31>> So in medical school, menopause just

1:33gets shoved into a tiny box. This is a

1:35scary statistic. So Oh my god,

1:38>> it's crazy.

1:38>> I just think it's insane. This is why we

1:40need to create change.

1:44This might be one of the most important

1:45conversations we ever have on the diio

1:47because women's health has long been a

1:50total mystery to so many people and so

1:52many people are struggling with all of

1:53the issues that we're going to talk

1:54about today with their menstrual cycles,

1:56PCOS, endometriosis, with diet, with

1:58understanding how to exercise as a

2:01woman. It's probably never going to be

2:02the case again that these four

2:04individuals that at the very top of

2:06women's health in their fields will be

2:09in the same place at the same time

2:11having this conversation. We structured

2:13this conversation into two parts. They

2:16cover completely different subjects, but

2:18they're fundamentally interlin. For me,

2:20the understanding that I got from this

2:22conversation at this table with these

2:23four women has fundamentally changed my

2:26life. It's going to change how I deal

2:27with my romantic partner, my sister, my

2:30team members that I work with every

2:32single day. And funnily enough, because

2:34it's a conversation I wouldn't have

2:36clicked as a man, it turned out to be

2:39the conversation that I needed the most.

2:40And I don't think I've ever said this

2:42before, but if there was ever an episode

2:44to share with a loved one, then this is

2:46that episode. Please share this episode

2:48with as many women as you can, but also

2:51with as many men as you can.

2:54[Music]

2:57Ladies, we should start with some

2:58introductions. Could you give me a brief

3:00introduction, Stacy, as it relates to

3:03your perspective and your experience and

3:04what your sort of bias is as it comes to

3:06this debate? When I say bias, I mean

3:08your your your experience and your your

3:11research that you're lending to this

3:12conversation today.

3:14>> I come from the exercise fizz and sports

3:16med background. Um, so I'm always

3:18looking through the lens of activity and

3:21nutrition and how that has a impact on

3:25our stress and our stress outcomes and

3:27how we can adapt to specific applied

3:30stressors especially when we're looking

3:32at improving health span, improving

3:34mood, improving body composition, all of

3:37those things. I've worked with and still

3:40work with uh the subset of active women.

3:43Um, I come from an endurance and a

3:44high-profile high performance sport

3:46background. So, that's where I've gotten

3:48my chops and then brought it over into

3:50the general recreational female athlete

3:53kind of perspective. Natalie,

3:56>> I'm a fertility doctor and every day I

3:58help patients with IVF get pregnant

4:00because I have an IVF clinic. But my big

4:02passion has always been natural

4:03fertility after I experienced my own

4:05pregnancy losses. trying to understand

4:08how we interact with the world and how

4:10that changes our hormones and help women

4:12understand what their hormones are, what

4:14natural fertility is, what happens as we

4:17age to our bodies, our eggs and our

4:19hormones, and let them be better

4:21stewards of their own fertility and

4:23their own health decisions.

4:25>> Mary,

4:26>> I have a background in general OBGYn, so

4:29I'm considered to be a women's health

4:31specialist. And it wasn't until I kind

4:33of went through my own menopause that I

4:36realized that there was significant gap

4:38in my training. You know, hearing

4:41watching Dr. Sims on um I think your

4:44podcast talking about how women are not

4:46little men really struck such a chord

4:49with me and made me realize I was

4:50siloing women's health to the

4:52reproductive organs, the breast, the

4:54uterus, the ovaries, the vagina and that

4:58if I really wanted to make a difference

5:00in a woman's whole health life, this

5:01last 30 years, 30, 40 years of her life,

5:04I needed to refocus

5:06what we were thinking about women's

5:08health for the long term. So I come from

5:11a background in academics. I was a

5:13professor for 20 years. I was a

5:15residency program director. Stepped away

5:17from that so I could focus on the lack

5:19of my own education and knowledge in

5:21menopause care. And now I want to step

5:23back into the academic world to bring

5:24everything I've learned and change the

5:26way we educate our providers. Vonda

5:30>> I am a orthopedic sports surgeon by

5:33training and I sit at the unique

5:34juxtaposition of orthopedics and

5:36performance having taken care of elite

5:39athletes most of my life aging and

5:41longevity most of my academic research I

5:44too as an academic is on subjects of

5:47muscularkeeletal aging but many years

5:49ago added a third circle of the whole

5:52health of a woman and so sitting in this

5:54place it fits directly into the mantra

5:57of my career which has always been I am

5:59going to change the way we age in this

6:01country and the world because the tool

6:04that I bring to the table is the fact

6:07that if I save your mobility I'm going

6:09to save you from the ravages of chronic

6:11disease and so the work that I do is not

6:15only educational it's uh research and

6:18it's now education of the world about

6:21these subjects

6:22>> explain this to me like I'm an idiot

6:24ladies why do we need to have a

6:26conversation about women's health and

6:27not just health broadly.

6:29>> I think the statistic that people don't

6:31realize on a day-to-day basis is that

6:33women are 51% of the population. We're

6:36actually not a minority. We're the

6:38majority and yet often our health, our

6:41healthc care access, the research treats

6:44us as if we're a niche product,

6:47>> but we are the majority product.

6:51We have to have this conversation

6:53because data show that

6:56of the $450 billion dollars spent on

7:00research in this country alone, less

7:01than 1% is spent on women over 40.

7:05>> And yet we are nearly 90 million people.

7:09And we make 80% of all the health care

7:11decisions in this country for ourselves

7:14and everyone we touch. And so even

7:17though when you look at the the

7:19long-term data, women are winning the

7:21longevity race here. We're living an

7:24average of 6 years longer than men. But

7:26as all of us talk about all the time,

7:29women suffer longer.

7:30>> Yeah.

7:31>> We're living 20% more of our lives

7:33versus our male counterparts in poor

7:35health with chronic disease or mental

7:38health disorders. And so McKenzie looked

7:40at the data and it was for the Gates

7:42Foundation and what they found was yes,

7:45we live longer. We've all known that.

7:47However, we have, you know, twice as

7:50high of mental health disorders. We're

7:53two times as more likely to end up in a

7:54nursing home. We are much more likely to

7:57lose our long-term independence from

7:59frailty or dementia, much more than our

8:01age matched male counterparts. And

8:03that's I think what we're all trying to

8:04fight here. And diseases that impact

8:07women specifically and only things like

8:09PCOS, endometriosis are extensively

8:13underfunded and not researched. It takes

8:15women 7 to 10 years to get a diagnosis

8:17of endometriosis after symptoms start.

8:20And we know this is a disease that

8:22impacts your entire body in addition to

8:25your fertility. But women are dismissed.

8:27They're not taken seriously. and there's

8:30not research guiding what we can do in a

8:33lot of these situations to try to help

8:35them the best.

8:36>> Why isn't the research there? Why why

8:38don't they research if women are the

8:41majority of the population? Why is all

8:43the funding going to researching men?

8:45>> You have to think about who was in the

8:46room when medicine and science first

8:48started. So if you think about back when

8:51the industrial revolution and the

8:53modernization of what we know is

8:55medicine, women were pushed out because

8:57they were believed to have smaller

8:59brains. thanks to Darwin and not thought

9:02to have a seat at the table. So when

9:04you're thinking about designing studies,

9:06it was pretty much designed on the male

9:08physiology on the male body and then

9:10women were an afterthought. So there

9:12wasn't any real in-depth look of well

9:15women are different from birth or in

9:17utero XX is different from XY. So all

9:21the research has just been generalized

9:23to women. Even things like aspirin for

9:25heart attacks and thinning blood

9:28>> inhibitors. Yeah, all of this all of

9:30this was done on men and then just

9:32generalized to women and now that we're

9:34having this global conversation on

9:36women's health, people are like, well,

9:38where is the information specific for

9:40women? And there's just a very small

9:42subset. So, we're looking and trying to

9:44expand that, but we have a lot of

9:46catching up to do. And that's primarily

9:49not only because of what you said, but

9:51the shocking statistic is that not until

9:531993

9:55were women required to be represented in

9:58studies. 1993,

10:00I mean, we were all far into our our

10:03lives in research by then.

10:05>> Isn't that a shocking?

10:06>> That's crazy.

10:07>> And there were still loopholes where

10:08people were finding ways to exclude

10:10women and then

10:11>> right, we're still not at 50%. No,

10:14>> we're harder to study. You have

10:15menstrual cycle, hormonal fluctuations,

10:18even menopause, pre even the animal

10:20models.

10:21>> It's not that we're harder to study. It

10:22just makes it presumed harder to study.

10:24There's more variables at play,

10:25>> right? It's more of a complexity to the

10:29research, but it's not more difficult.

10:31And this is where I bring it in. It's

10:32like if a woman had a seat at the table

10:33when all the study designs were started,

10:36it wouldn't be a question. It would just

10:38have been assimilated in. because we've

10:40been so drawn into we have a crossover,

10:43here's one week crossover, next week

10:45because of male physiology. When you add

10:47women's hormone fluctuations and people

10:49like, "Oh, it's too complex."

10:50>> Right? But it's not.

10:51>> What is it that makes, and this is a

10:53super dumb question, but an important

10:54one. What is it that makes men and women

10:56different from a physiological

10:57standpoint? Because to understand why

11:00research would need to be done

11:01separately, we need to understand the

11:03differences.

11:04>> Yeah. Well, I mean, we can look from a

11:06morphological standpoint where men have

11:10more of our fast twitch fibers. Women

11:12are born with more endurance fibers,

11:14>> which is muscle, right?

11:15>> Uh when we're talking about muscle.

11:16Yeah. So, uh men have more of the

11:19ability to do power and and really fast

11:23energetic type activities or women are

11:25more attuned to endurance type

11:27activities. And this affects metabolism.

11:29It affects blood glucose homeostasis.

11:32And when we're looking at bone and bone

11:34density, men have stronger bones. Uh

11:37they can acquire more load. They hold on

11:39to it better than women do. We see

11:42smaller lungs, smaller heart, less

11:44hemoglobin in women than men. And that's

11:46an offshoot of what testosterone does.

11:49So there are just basic physiological

11:51differences between XX and XY that

11:55people don't really assimilate and

11:57understand. And the way I like to say it

11:59is you go into a shop and you have a

12:01men's section and a women's section and

12:02there are touch points on the external

12:05that really identify gender andor sex.

12:08But when you look intrinsically no one

12:10is identifying those touch points until

12:11now. Also when we look at how we disease

12:15so in cardiovascular disease is is

12:17aththeroscerotic disease is the best

12:19example. Men tend to have their

12:22blockages. So aththeroscerotic disease

12:24is basically the plaques that build up

12:25in the coronary arteries around the

12:27heart. Men tend to develop their plaques

12:30very early right as those arteries exit

12:32the aorta and dive into the heart

12:33muscle. So we get what we call the

12:35widowmaker. Okay? It's called that for a

12:37reason because men die and they make a

12:39widow. And so that's the left anterior

12:41descending artery. Women by and large

12:44tend to not have these larger artery

12:47blockages, but their blockages are

12:48diffuse and microvascular deeper into

12:51the heart muscle, which is why we

12:53present with a heart attack much

12:55differently than a man does. And those

12:58we're not teaching our, you know, we're

12:59not educating our clinicians as to these

13:02differences. Women are considered to

13:03have atypical chest pain. Dr. Wright,

13:0651% of the population is female. Why are

13:08why is my heart attack atypical

13:10>> and a man's typical? But this happens

13:13not only at the organ level. It makes

13:16sense that if we have a population with

13:18XX chromosomes, a population with XY

13:21genetically and the way we express those

13:24genes are differently. But I think we

13:27miss the fact that down to a cellular

13:29level, every cell from an XX is

13:32expresses these tissue changes, tissue

13:36manifestations differently than an XY.

13:39Our lab used to study, we called them

13:41muscle derived stem cells so 20 years

13:43ago. Now they're called satellite cells.

13:45But when we harvested them and asked

13:47them to behave and in different

13:50environments,

13:51satellite cells from XX people and XX

13:55animals, women, females were better

13:59under the same circumstances

14:01experimentally

14:03at making cartilage and muscle. XY male

14:08were better under the same circumstances

14:10in making bone. So down to a cellular

14:14level, we express our genes differently.

14:16It should be no mystery to us or anybody

14:19else that there are differences. And yet

14:22there is the propensity just to lump us

14:24all in the same basket and almost say I

14:28almost sometimes feel as pjorative to

14:30say, oh the women are different. Of

14:32course they're different. Yeah,

14:34>> we're genetically different

14:35>> down to every cell in our body.

14:36>> Every cell. So, it should be no surprise

14:39to anybody, but it it seems to be a

14:40surprise.

14:41>> Seems to be a surprise all the time.

14:43Yeah. I get pushed back all the time.

14:44There's no difference. Yes, there is.

14:46There is. And it's not just bad. It's

14:49just is.

14:50>> Yeah. There's Yeah.

14:51>> Because at one point that was quite a

14:52controversial thing to say, wasn't it?

14:54To point at the differences between men

14:55and women.

14:56>> Mhm. Outside of, you know, our different

14:58organs. Yeah. You know.

15:00>> Yeah. And because of this research gap

15:02and the bias in medicine, um, women have

15:05been misunderstood by their male

15:07counterparts in a number of ways. I

15:08remember I think it was you, Mary, that

15:09was telling me about this whiny women

15:11thing that you were exposed to.

15:13>> When I was in training and and you all

15:15may have similar stories and I just

15:17heard a new one the other day, my first

15:20patient in gynecology clinic, I'm an

15:21intern. I'm very excited. You know, we

15:23have our stacks of charts. That's how

15:24old I am. We had paper charts. I pick up

15:26the chart, open it up. It's a

15:2840-year-old woman with multiple vague

15:30complaints. She's gained some weight.

15:32She's a little bit depressed. Her libido

15:34is off. Her blood pressure is a little

15:36bit up. Her cholesterol is starting to

15:38rise. And she's seen family medicine.

15:39Like we're the third or fourth doctor at

15:41this point. And so my upper level who

15:43happened to be male this, you know, it

15:45could have been anyone. Walks down the

15:47hall in his cowboy boots cuz Texas. And

15:49um and he's like, "What you got?" And I

15:51said, "Well, I have Miss Smith,

15:53whomever, you know, she's a 40-year-old

15:54woman with." And I list the complaints.

15:56And he goes, "Did you check her thyroid?

15:57Family medicine did. Did you check this,

15:59you know, a few simple labs?" And he

16:01goes, "Hm,

16:03you got a WW."

16:05And I said, "What's I don't know this,

16:08you know." And he said, "Uh, don't write

16:10this in the chart, but we call that a

16:12whiny woman around here."

16:14>> Oh my gosh.

16:15>> And I said, "Okay." He said, "Listen,

16:18women just tend to go through this at

16:20this age, and we're not really going to

16:23be able to help her. pat her on the

16:25knee, tell her to have some wine, go on

16:27date night, you know, she'll get better,

16:29but we're not going to be able to help

16:30her. And that stayed with me. Now, I

16:33was, you know, a good girl. I did what I

16:35was told. You know, it took me 20 years

16:37of internalization to realize this, you

16:40know, I don't want to blame him. He's

16:42not a bad guy. This was taught to him.

16:44But this kind of thinking, I mean, I saw

16:47this in the ER. I saw this in the O. I

16:49saw this in every clinic. And so I've

16:51asked other clinicians around the

16:52country and I've heard whiny gyne status

16:55Hispanicus total TBD total body delore

16:58like in different regional areas there

17:00was a name for this kind of vague

17:03complaints from this middle-aged woman

17:05and we couldn't quite put our finger on

17:07it and I realized this was systemic bias

17:10built into the system where women and

17:12there's historical you know precedent

17:14for this the wandering uterus the

17:16hysteria you know these were real

17:18medical terms just until like not even a

17:21generation ago.

17:22>> Yeah. They used to put women into

17:24asylums.

17:24>> Yeah.

17:25>> Because of hysteria and it was hot

17:28flashes, all the things that that are

17:29now known with permenopause. They used

17:31to think it was some kind of insanity

17:34and put women into insane asylums to

17:36lock them down.

17:38>> But this is pervasive. Not just an OB.

17:40You're not the only guilty. It's every

17:42medical subsp specialty has some

17:47culture

17:48of for lack of better words blowing

17:50women off it right. We're not having the

17:54curiosity that defines medicine. We are

17:57supposed to be curious people. But yet

17:59when it comes to this, why do we stop at

18:03just seems to be something that happens

18:04to middle-aged women, right? it that

18:06that's written in the orthopedic

18:08literature seems to happen to

18:10middle-aged. Where's the curiosity?

18:13>> Where was it?

18:14>> Yeah. Well, in X-fist text, you always

18:16had the representative of him or they

18:18and the vuvius man and all the angles of

18:22the male body, but there was never

18:23representation of women. The only time

18:26you heard about a female athlete was all

18:28the pathophysiology. You know, the iron

18:30deficiency, the female athlete triad,

18:32which we now call um relative energy

18:35deficiency in sport.

18:36>> And when you're looking at the

18:38historical idea of sport, the only way

18:40women were actually included and

18:43accepted is when they were amenic

18:45because then they were quote more like

18:46men and then there wasn't a problem with

18:49training them and then they could work

18:50as hard. But we know that that's not

18:53appropriate. That's a sign of of illness

18:55and overtraining under recovery. So, it

18:58is pervasive everywhere. It's not just

19:00the medical, but it goes into when you

19:02think about what it means to be

19:03successful in sport. It's the power.

19:05It's the aggression. It's the

19:07unfallibility of being human. And a

19:09woman having a menstrual cycle was

19:11deemed a fallibility. So, they're trying

19:13to push it aside. This is so systemic

19:15though that women downplay their own

19:18complaints. They gaslight themselves. It

19:21takes them a long time to seek care

19:23because they're afraid of the response.

19:26They are not always honest with what's

19:28going on in their body. I'll say, "Do

19:29you have pain?" "Oh, no more than

19:31regular." They downplay everything. You

19:33have to really ask. And it's almost the

19:36society, I don't want to be viewed as

19:38this way. I don't want to be not taken

19:41seriously. And it causes them an to have

19:44an even harder time to get to a

19:46diagnosis because they don't feel

19:47comfortable sharing some of these

19:49symptoms or they've downplayed them in

19:50their life so much. This is why they

19:52have to get so sick to often present to

19:55even try to get care. And they come to

19:58me almost to a woman after I'm talking

20:01about whatever muscularkeeletal thing

20:04they'll say even before they want to

20:06describe it to me. They'll say, "But you

20:09know, I have a really high pain

20:11tolerance." Yes. Mhm.

20:12>> Like it's a badge because we've been

20:14conditioned to not come for any pain.

20:17But I've suffered. I've tried. That's

20:19why your arm doesn't move anymore. I've

20:21got such a high pain tolerance, but I

20:23couldn't take it anymore. I didn't want

20:25to come. And I feel like why does it

20:28have to be that way?

20:30>> So, you train treating both males and

20:32females. I I was locked in a room with

20:34women for 25 years, you know, and so

20:37it's so fascinating to me to hear how

20:41men and women come in with the same

20:43complaint in your clinic, in your

20:44fellowship, all those years you spent

20:46training, and yet you were taught to

20:49treat them differently, you know, and

20:50the urologists say the same thing, you

20:52know, who

20:52>> I don't think I was aware of it.

20:54>> Yeah.

20:54>> There was just that's

20:57so much bias. Yeah.

20:59>> I didn't realize. I didn't either

21:00>> because like you, until I went through

21:02my own pmenopause,

21:05I might not have paid it attention to

21:07it.

21:08>> Yeah,

21:08>> I may have been less sensitive.

21:11>> I was a terrible menopause.

21:13>> I see messages all the time in the

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21:23It's the simple, it's the free thing

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21:31double check if you've subscribed and uh

21:33thank you so much because it's strange

21:35where you are you're part of our history

21:37and you're on this journey with us and I

21:39appreciate you for that. So, yeah, thank

21:40you. Is that in part because we know

21:42very little about hormones as well. When

21:44I was speaking to our audience, we asked

21:46a thousand women to submit their

21:47questions ahead of this conversation.

21:48And one of the most asked questions, all

21:52the most asked questions sort of related

21:54to understanding hormones. I think the

21:57conversation around hormones is quite a

21:59new one in society and I actually think

22:01it's been driven a lot by a heightened

22:03understanding of menopause generally. I

22:05think the the conversation of hormones

22:07around outside of fertility and the

22:11general menstrual cycle. I can right now

22:12draw from memory the exactly what's

22:15going to happen in a normal menstrual

22:16cycle. We were taught that, you know,

22:19very very well. But when I saw maybe 3

22:22years ago an academic paper that showed

22:25all of the locations of the G-coupled

22:28estrogen receptors in the human body,

22:30>> what's that?

22:30>> I lost my mind. So basically, where are

22:33the estrogen receptors in the human

22:34body? And they're everywhere. The brain,

22:37the bones, the muscle, the gut, you

22:39know, the the every almost nothing. The

22:42the the endothelial, the lining of the

22:45individual blood vessels around our

22:46heart, you know, it's really radical to

22:49me to think about how all these sex

22:52hormones are the progesterone, estrogen,

22:54testosterone, hormones are everywhere.

22:57>> What is a hormone?

22:58>> They're not actually sex hormones.

22:59hormones are your body's communication

23:01system, right? So, it is really how your

23:03body is sending out messengers to

23:05communicate. So, a hormone is dictating

23:07an action and I think there's going to

23:09be a lot of great discussion. But one

23:11thing that I think is very important to

23:13your point, Stephen, is even things that

23:16we were readily taught about the

23:17menstrual cycle and estrogen,

23:19progesterone, testosterone, the public

23:21is now becoming aware of because we've

23:22not done a good job at public education

23:24that this is what's really happening in

23:26your body. this is what your menstrual

23:28cycle is. This is what happens when you

23:30go through menopause. This is what

23:32happens when you're trying to train for

23:34a sport. We haven't had these

23:36discussions publicly that we are seeing.

23:39And I think that is highlighting

23:41interest in all of this even if some of

23:43us were taught some of this. But when it

23:46comes to hormones there, everybody wants

23:49really easy fast. Draw my level. Tell me

23:51what to do. Give me a medicine. Fix it.

23:54And I think the most important thing to

23:55understand is that by definition, your

23:58hormones are dynamic. Your body is

24:01responding to the hormonal signal it

24:03sees and determining what next signal to

24:06send out. So constant fluctuation

24:09throughout the day in response to

24:11multiple stimuli. And that's how it's

24:13supposed to be. If we didn't do that,

24:15we'd all be dead.

24:16>> It's a symphony. But that makes it

24:17really hard for somebody to understand

24:19on the other end who's not in medicine

24:20who says, "Well, is it my hormones?"

24:24Because there's no one test that's going

24:25to give you one answer. You have to

24:27really interpret it in context of the

24:29full body. And it makes it really hard

24:31for practitioners who do not understand

24:33the hormones as well. And we see a lot

24:35of mismanagement of hormonal scenarios

24:37and situations right now that are

24:39actually detrimental to patients. So,

24:41I'm glad you're having this discussion

24:43because that's not a stupid question.

24:45What is a hormone? Many people don't

24:47really understand that.

24:48>> What is the I really want to make sure

24:50that if someone for both the men that

24:52probably have less understanding but

24:53also from our conversations I've

24:54realized and the feedback I've gotten a

24:56lot of women don't understand their own

24:58hormones and their own menstrual cycles.

25:00What is the most basic level that we

25:02have to start at to give people an

25:03understanding that we can then build on

25:06of what's going on here?

25:07>> I was say I want to get rid of this

25:09graph.

25:10>> Okay. So that leave it out. Leave it

25:13out. But it it shows just a textbook of

25:17what a menstrual cycle is is, but it

25:19doesn't show the daily perturbations of

25:22estrogen and the luteinizing hormone

25:24pulses and all the things that go as

25:26Natalie is saying to make it to make it

25:29work.

25:30>> You see two organs there, the ovary and

25:31the endometrial lining. You're not

25:33seeing the muscle, the bone, the brain.

25:36All of those organs are affected by

25:38these normal monthly fluctuations.

25:40>> Yeah. And the conversation that we're

25:41having now in research methodology is

25:45the fact that there is no real

25:47definition of normal cuz every woman's

25:49cycle is variable. So when we look at

25:52this, everyone thinks that this is

25:53normal but we don't actually know if

25:56that is for the fact that a woman's

25:59variation

26:00this can change cycle to cycle. This can

26:03change cycle to cycle. Sometimes we have

26:05an ovulatory cycles. So until a woman

26:08can identify what her own normal is, we

26:10can't rely on this graph to actually

26:12explain to them.

26:13>> How does a woman know what their normal

26:15is versus, you know, because a lot of

26:17women are on birth control pills since a

26:19very young age. So I think my partner

26:20Melanie, she's she was on birth control

26:22for about a decade. So she like didn't

26:24have her cycle and then it came back and

26:26it was every I don't know 60 90 days.

26:28>> Mhm.

26:29>> And then she changed her diet a little

26:30bit and it kind of went down to 30 days

26:32over time. But I don't think she knew

26:34what normal was. Is there such thing as

26:36normal?

26:37>> I mean there is what should be normal

26:38for you. So you should have a regular

26:41predictable period which means that you

26:43are having a menstrual bleed at a

26:45predictable interval. It can range

26:46person to person but for you really it

26:49should be within a couple days

26:50monthtomonth. I always tell patients I

26:52should be able to give you a calendar.

26:53You should be able to take your finger

26:54pick when your next period is coming and

26:56within a few days be accurate. Now

27:00usually that range is somewhere between

27:0225 and 35 days for the average person.

27:04when it starts to get shorter or longer,

27:06it can be a warning sign that something

27:08is going on. When it comes to the

27:11menstrual cycle, because I think we're

27:12going to talk about these hormones

27:14really well, and I talk about this every

27:16day, let's give a one minute

27:18explanation. If we think about to

27:20Stacy's point from the brain, the brain

27:22is sending out pulses of hormones, but

27:24FSH drives egg growth. It's called

27:26follicle stimulating hormone, and each

27:28egg is inside a follicle. So, you have a

27:30group of follicles inside the ovary. FSH

27:32comes from the brain, grabs one of them

27:34and gets it to grow and it makes

27:36estrogen and this estrogen from the

27:38ovary as the egg is growing is called

27:40estradiol and it's the primary type of

27:42estrogen in your body. So it is rising

27:45and when it gets to a peak level and the

27:47body is so fascinating because it's 200

27:49pogs for 50 hours is a very exact

27:52amount. Then the brain says we must have

27:54a mature egg and it kicks out a surge of

27:57luteinizing hormone or LH and that is

28:00going to allow the follicle to rupture

28:02the egg to be released and the follicle

28:04to reform and then become a corpus

28:06ludium and then the brain's going to

28:08send out pulses of LH giving you pulses

28:11of progesterone. So Stacy's point

28:13>> that's an average and those numbers on

28:15the little graph are nowhere near

28:16accurate because progesterone goes up

28:18and down the entire second half of the

28:20cycle known as the ludial phase. What's

28:22progesterone?

28:23>> Progesterone is also made from the

28:24ovary. So, the two main hormones when it

28:26comes to a premenopausal female are

28:29going to be estrogen and progesterone.

28:31Progesterone is the progesterational

28:33hormone or progreg. It is going to

28:36change the endometrial lining and it is

28:38essential to get pregnant. It opens and

28:40closes the implantation window within

28:42the uterus and it completely changes the

28:45physiology of your body. And we're going

28:47to talk a lot that is why in the ludal

28:48phase your body works differently when

28:51you have progesterone

28:52>> and the lutial phases

28:54>> after ovulation when you have a corpus

28:55ludium. So when LH is coming from the

28:58brain you have a corpus ludium it makes

29:00progesterone. This is the second half of

29:02the cycle known as the ludal phase. The

29:04first half when you have estrogen only

29:06is the follicular phase. So you have an

29:08estrogen dominant phase and then you

29:10have a phase where you have both

29:11estrogen and progesterone. And your body

29:13is made Yes. So we have our estrogen

29:16dominant phase, the follicular phase,

29:18and then we have we have both estrogen

29:19and progesterone here in the ludial

29:21phase. And your body is made to function

29:23differently in these because in the

29:24progesterone side, it's preparing you

29:27for a pregnancy. It thinks every month

29:28you might get pregnant and it starts to

29:30change how your body's going to work on

29:33a cellular level. But if you don't get

29:35pregnant, that progesterone level is

29:36going to drop and the cycle starts back

29:38over.

29:39>> And from um like a exercise and sports

29:42>> Yeah. point of view. When we get into

29:44this, the progesterone's job is to build

29:46this lush endometrial lining and it

29:50creates a lot of glycogen storage. So,

29:52we often hear about glycogen in the

29:54muscle and that's what we're using for

29:55fuel. It has a way of shuttling a lot of

29:59the carbohydrate away and storing it

30:01into the endometrial lining, which is

30:03why we see differences in intensity and

30:06the way that a woman can respond to

30:08exercise if she has ovulated. So is this

30:11in preparation of a potential baby?

30:14>> Yeah, correct. Yeah. In the second half

30:15of the cycle, your core body temperature

30:18increases, your resting heart rate is

30:20higher, your heart rate variability is

30:22lower, you have increase in fatigue, you

30:25have an increased appetite, your body is

30:27shifting function in case an embryo

30:29comes in so that it can start to divert

30:31energy and change what it is doing right

30:34down to your immune system changes.

30:35>> And that's roughly from day 14 roughly.

30:38>> Roughly. Yeah. Yeah. At ovulation, it's

30:40about 3 days after whatever day. If

30:41you'd like to be specific, it's about 3

30:43days after ovulation until when you get

30:45your next period.

30:46>> Yeah.

30:46>> You all talk about how our menstrual

30:49cycles can be a broader sign of whole

30:51body health.

30:52>> Mhm.

30:53>> And um so should if someone's menstrual

30:55cycle is irregular, should they be

30:57concerned?

30:57>> Yes.

30:58>> Yes.

30:59>> I thought you were going to say no.

31:02>> How irregular? What's like if I'm not

31:04getting my menstrual cycle?

31:05>> Absolutely not good. You should go see a

31:07doctor. Yeah, if your cycle is

31:09irregular, if the calendar trick, you're

31:11putting your finger and it's nowhere

31:13near when your cycle's coming. Or I have

31:15women who say, "Oh, there's no way I

31:16could predict it." Or, "I know it will

31:18come, but it'll come every 4 to 6

31:20weeks." Your body's meant to work like

31:23clockwork when it comes to your your

31:25hormones and your menstrual cycle. And

31:27yes, you can always have one abnormal

31:28month, always. But when you consistently

31:31are having irregularity, that is a sign

31:34that something else is going on. It's

31:35one of the biggest red flags that we

31:37have for early hormonal health or

31:39systemic problems. But to your earlier

31:41point, Stephen, we have a generation of

31:43women on contraceptive options who are

31:45not tracking their cycles. We have women

31:47who are not taught how to track their

31:48cycles. They don't know when ovulation

31:50occurs. They don't know how long their

31:52ludal phase is. If I say the first sign

31:55of ovulatory dysfunction or having a

31:57problem with your cycle is a short ludal

31:59phase, well, you only know that if

32:02you're tracking when ovulation occurs

32:03because otherwise you could still have a

32:05regular cycle, but you don't know that

32:08something's abnormal.

32:09>> And that lut your phase again is the

32:10last the last half of your your cycle.

32:13>> Exactly. But I think that the

32:15conversation that's happening now is so

32:18not just at this table but in society

32:20that our monthly cycle is so much more

32:24than getting ready to have a baby

32:26because I think that none of us knew

32:28this.

32:29>> No.

32:30>> Because at 17 I wasn't that interested

32:33in having a baby. So it didn't occur to

32:34me that I should care.

32:36>> Right.

32:36>> Right. And it's the only time if you're

32:40thinking about it in that way that

32:41you're worried about your period is if

32:43you don't have one and pregnancy, right?

32:46And so if we're shifting the

32:48conversation to this is physiology, this

32:52is has to do with every part of female

32:54physiology,

32:56maybe it will be easier for people to

32:59know,

33:00right?

33:01>> Yeah. I often put it with u my athletes

33:04that it's a marker of health that if you

33:05are able to take on the load of

33:07training, the load of travel and

33:09maintain your normal menstrual cycle,

33:12then you are robust enough to be able to

33:15progress. But if there becomes a misstep

33:18in your menstrual cycle, then we need to

33:20look at all the stressors that are and

33:22the allosic load and pull you back and

33:25see what do we need to address? Do you

33:27need to eat more? Do you need to recover

33:28more? what are the things that are

33:30missing to bring you back to normal?

33:32>> I was diagnosed with polycystic ovarian

33:34syndrome in medical school and so like

33:37every medical student of course it was

33:38like gloom and doom and I you know

33:40thought I had the most extreme case ever

33:42known to mankind. It was really just

33:44garden variety PCOS and I had very

33:47serious boyfriend quickly engaged you

33:49know looking forward to having a family

33:50with him starting a family with him and

33:53the terror around my infertility and

33:56what the impact was. What was never

33:58taught to me and what I didn't

34:00understand until much later was the

34:02metabolic impact. Like PCOS is a

34:05symptom. There's nothing wrong with my

34:06ovaries. They're just responding to this

34:08high insulin level I was born with. And

34:11no one really sat me down and talked to

34:13me about my first research project was

34:15women with irregular periods and the

34:16risk of developing gestational diabetes

34:18and and you know I didn't even know what

34:20insulin resistance was at the time. And

34:24now we're coming to understand that, you

34:26know, when these young women are coming,

34:28you know, I only do menopause now, but

34:30before I left that practice, you know,

34:32when women were coming with the regular

34:34cycles and we were making these

34:35diagnosis, immediately I was launching

34:36into the discussion about her metabolic

34:38health long term and what this, you

34:41know, it's a gift to know this. So now

34:43we can start making interventions,

34:44nutrition, diet, exercise to give you a

34:49better system to deal with this thing

34:50that you were born with and her

34:52fertility. Of course,

34:53>> a huge amount of women have PCOS and I

34:55think that's one of the leading one of

34:56the leading one of the top causes of

34:58having irregular menstrual cycles. You

35:01you mentioned insulin resistance and

35:04metabolic dysfunction there. And you

35:05said something like diabet gestational

35:08diabetes,

35:08>> diabetes in pregnancy. So someone who

35:10was non-diabetic before pregnancy and

35:14then develops diabetes. So her blood

35:16sugars have now reached a threshold

35:18where they are higher than normal and

35:20can cause you know problems for her

35:22pregnancy and herself long term. And up

35:25to 50% of those patients de who develop

35:27diabetes in pregnancy will develop type

35:312 diabetes within 10 to 15 years after

35:33that gestation after being pregnant. And

35:36so what we know now is like we have

35:38warning signs of this well before

35:40pregnancy where we can set these women

35:42up for success. Before it's just we wait

35:44till we make the diagnosis, everybody

35:46gets their glucose test and off you go.

35:48But now with this PCOS diagnosis, we are

35:52monitoring earlier. We're starting her

35:53on the nutrition. You know, we're

35:55treating her like a diabetic with

35:56nutrition and exercise recommendations

35:59rather than waiting till she she reaches

36:01the criteria. Stephen, having

36:03infertility, this is a scary statistic.

36:05It predisposes you to many medical

36:09problems later in life, including an 80%

36:12higher chance of having a heart attack,

36:1475% higher chance having metabolic

36:16syndrome, higher risk of cancer, and

36:17early death. Why infertility? Well, it's

36:20not exactly that infertility is causing

36:22this, but it's that for many women,

36:24we'll use Dr. Haver's example, you're

36:27healthy until you get this diagnosis.

36:29It's one of the first warning signs your

36:31body's giving you that there might be

36:33inflammation and insulin resistance or

36:35something impacting your hormones, your

36:38menstrual cycle, your ability to

36:39conceive that if it is not corrected now

36:43is setting you up for many problems down

36:45the road. PCOS is a example of this

36:48because in PCOS you have a lot of eggs

36:51inside the ovary. It's actually

36:53something that genetically runs in

36:56families. likely there's something that

36:58happens when you're a baby inside your

36:59mom that predisposes your ovary to not

37:02lose as many eggs as it should and it

37:04changes how they respond to insulin. So

37:06what happens is you end up having more

37:09eggs on an average. Your brain doesn't

37:12know this and sends out the average

37:13signals but that gets diluted amongst

37:16all the eggs and so you're not getting

37:18into these ovulatory stages of Stacy's

37:20favorite graph here. Well, what happens

37:22from there is that you're actually in a

37:24relatively lower in estrogen phase than

37:26you should be. You never see the

37:28progesterone. And what happens is you

37:30start to completely shift. The ovary

37:32itself actually becomes insulin

37:34resistant. And what this means is that

37:37throughout your entire body, you start

37:40to develop high glucose, which is the

37:42blood, right? That's your blood sugar.

37:44Your blood sugar is the fuel for all

37:46your cells. All your cells need glucose.

37:48Well, insulin is the hormone that helps

37:50that glucose go from the bloodstream

37:51into your cells. Well, in insulin

37:53resistance, when your body sees high

37:55glucose all the time, it starts to send

37:57out more insulin saying, "Hey, we need

37:59to get this into cells, but the cells

38:01start to, oh, I'm used to insulin being

38:03here, so I'm not going to respond." It's

38:06going to take a higher insulin signal to

38:08get the cell to open up the door and let

38:10glucose comes in. This becomes very

38:13problematic especially in we'll say PCOS

38:16because that insulin is very

38:17inflammatory causes you to get extra fat

38:20stored in different places. It also just

38:23completely changes how your body your

38:25metabolic health in general but also

38:27your hormonal health and in your brain

38:29because your brain sees this and says

38:30why are we keeping glucose in our in our

38:32bloodstream is what's going on heightens

38:35everything. And so this resistance to

38:37insulin actually shifts how your brain's

38:40going to respond to hormones, therefore

38:42the hormones it's sending out. And it's

38:43a self-perpetuating cycle. And a lot of

38:47when we talk about lifestyle mechanisms

38:49to improve hormonal health, which I know

38:51that we all will, a lot of that is

38:53targeting improving insulin resistance

38:56and combating inflammation because those

38:59two players, a lot of it is controlled

39:01by the world around us and what we do to

39:04some degree. And especially if you have

39:05an underlying diagnosis like PCOS,

39:08>> endometriosis, which is a chronic

39:10inflammatory disease, autoimmune

39:12disease, you're at even higher risk. I

39:14always say your scale is already tipped

39:16in a way that's going to be really hard

39:18for you. You have to make active steps

39:20to fight what is happening inside your

39:22body.

39:23>> We'll talk about some of the ways one

39:25can reverse their PCOS, if that's even a

39:27possibility. Um, but again on the causal

39:30factors, is it something So my

39:32girlfriend's got PCOS. She's been very

39:34public about that. Um, is it something

39:36she did? Is it something she ate? Is it

39:39>> She was Is this the way she was born?

39:41So, she was born with a predisposition

39:43of having too many eggs. You lose most

39:45of the eggs inside your body when you're

39:46a baby inside your mother's womb. You

39:48lose the next biggest set before you

39:50ever have your first period. Now, if you

39:53don't lose them for some reason, you're

39:55born with more and it interferes with

39:57how your hormones are supposed to

39:58communicate leading to this metabolic

40:01issue and this insulin resistance. She

40:04did nothing to cause this. Nobody with

40:05PCOS caused it. However, what you said

40:07earlier, oh, she changed how she ate and

40:09her cycles got more regular.

40:12>> You can influence the severity of the

40:15symptoms that you experience with it. So

40:17even if you don't cause your disease cuz

40:19you did not,

40:20>> choices you make can make it absolutely

40:22can make it better or worse, just like

40:24any disease.

40:26>> And when you use the word insulin, I I

40:27think of or insulin resistance, I think

40:29of sugar.

40:30>> Mhm.

40:30>> Yeah. Because glucose is sugar

40:32essentially. And many people, and I'll

40:34have patients tell me this, I don't need

40:36to worry about insulin resistance

40:37because I don't have diabetes or it's

40:39not in my family. And we've so we've

40:42ingrained this word insulin resistance

40:44or talking about glucose or checking

40:46glucose with a diabetic or pre-diabetic

40:49state. But the world around us honestly

40:52promotes insulin resistance. It's it

40:55that's how our bodies we live in this

40:58obesogenic environment. I mean there's

41:00no doubt at least in the US you know and

41:03most industrialized nations our

41:05environment is what we call obesogenic

41:07insulin you know and insulin resistant

41:10so it you have to fight against kind of

41:13the systems that are in place now for

41:15most of us unless we have some genetic

41:17predisposition to just be you know

41:19magical um to because the way we process

41:23food the way food is delivered to

41:24communities the way you know our lack of

41:27exercise you know everyone's working

41:28from home now just just modern life is

41:31is really you have to fight against.

41:34>> One of the questions that came in from

41:35the audience was I would like to know

41:37how best to manage my PCOS.

41:39>> When it comes to managing your PCOS,

41:42targeting those two factors that we

41:43talked about earlier, insulin resistance

41:44and inflammation are really the key. And

41:47I'll let these two speak to a little bit

41:49of some of the exercise changes that we

41:51can try to impact. But what I'll say is

41:54that the best way to decrease

41:56inflammation in your body is going to be

41:58to start by focusing on your gut. Your

42:00gut health controls a lot of the

42:02inflammatory burden that your body sees.

42:04The foods you choose to eat, they can be

42:07both helpful if they have a lot of fiber

42:09in them. They can feed your gut

42:11microbiome, which is important in

42:13estrogen metabolism, but they can also

42:16be very harmful if they are

42:18ultrarocessed foods that are even

42:19causing more inflammation, not feeding

42:22your gut microbiome at all and

42:24worsening. So, I always say it's like a

42:25scale. If you think every little food I

42:28eat, it can make my insulin or it can

42:30make my inflammation better, it can make

42:32it worse. And so how we structure the

42:35food that we put in our body is one of

42:37the biggest changes the majority of

42:39people can make that is going to make a

42:41difference. And that's going to be a

42:43very plantforward diet. Doesn't mean

42:45it's plant only, but plants have fiber.

42:48Fruits and vegetables have fiber. So we

42:50have to make sure we're getting fiber as

42:53a big change. That's what we see. I see

42:55a lot of patients with PCOS specifically

42:57being told I shouldn't eat fruit. I

42:59shouldn't do this. I I need to avoid

43:02>> do the ketogenic. You need to do keto.

43:03Yes. So, we see people avoiding certain

43:06food groups. And I always say it's not a

43:07really sexy diet, but it's a it's a diet

43:09we all know.

43:10>> Lots of whole foods, fruits and

43:12vegetables, healthy fats, healthy

43:14sources of protein, avoiding the

43:16ultrarocessed foods. That's going to be

43:18probably the biggest change most people

43:19can make. In addition to foundational

43:22changes of your day, which is going to

43:23be sleep more, that is when your body

43:26fights inflammation, fights insulin

43:28resistance. work on decreasing chronic

43:32stress. To Stacy's point, you're not

43:34running from the bear. So, your body is

43:36not using that challenge, but you get a

43:39email. You get stressed and your body

43:42releases a lot of glucose so it can have

43:44sugar and fuel to run from a bear and

43:46there's no bear, right? And previous

43:48days that would happen and then you'd go

43:50run and that glucose would go into all

43:52of your muscles and your body would go

43:54back to normal. But now, we're

43:56chronically stressed. So, actively

43:58decreasing stress and then exercise,

44:01building and using skeletal muscle is

44:03one of the most effective ways to combat

44:05insulin resistance that exists. And

44:08since 80% of patients with PCOS have

44:10insulin resistance, a large portion of

44:13women with infertility, even without

44:15PCOS, have insulin resistance, that is a

44:18huge thing that people are missing,

44:21especially when it comes to the exercise

44:23discussion. And I know you guys probably

44:24have things to add on that one. No, but

44:27based on what you just I just took a

44:28phone call this morning from a patient

44:30when and it's just such a typical

44:33conversation. She doesn't like the way

44:36her body looks.

44:38>> Her solution is not to eat. It's this

44:41happens almost every day when I'm

44:43talking to people. It's we're having

44:45coffee for breakfast. We don't eat till

44:47midday when we do eat. So the the gut

44:51reaction because of the way many women

44:54are raised is that we're going to starve

44:56ourselves which is the opposite of good

44:58when it comes to physiologic wholeness

45:01and then you don't have the energy to do

45:03the kind of exercise you need or on the

45:06other side the response is I am going to

45:09work so hard every single day that you

45:13actually increase your stress there is

45:15over there is overtraining

45:18>> so you're just getting behind the

45:20eightball with starving yourself and

45:21overtraining. None of which are going to

45:23solve either the core problem due to

45:26PCOS or the core problem in any stage of

45:30a woman's life. Right.

45:31>> And this is where we look at the

45:32socioultural effect of what a woman is

45:34supposed to look like.

45:36>> Yeah.

45:36>> And that's the thing that I really

45:38pushing out. It's like we want to think

45:41about how strong we can be and how much

45:44muscle we can build because muscle is a

45:46massive metabolic help. Mhm.

45:49>> And as as well as bone, right? So, we

45:53talk about it and then when I get the

45:54push back of, oh, I'm going to do fasted

45:57training or I'm going to fast till noon.

45:58I'm like, wait a second. Not only were

46:00we going to interfere with our circadian

46:02rhythm and our hormone pulses, we're

46:04also acutely interfering with our

46:07appetite hormones because if we're

46:09looking at gerolin, which is our active

46:12form of of our appetite, makes us

46:14hungry. It's elevated with cortisol. And

46:16so if we're thinking about that

46:18elevation and we're not doing anything

46:19to drop it and tell our body we have

46:21food, then it goes in and directly

46:23affects our neuropeptides, which then

46:26affects our hormone, our hormone pulses.

46:28So when a woman's like, I'm just having

46:30coffee for breakfast and I'm going to

46:31hold my fast. It's like, okay, well,

46:33here we go. Cortisol is going up. As

46:35Gary, you're going to get hungrier. Then

46:36you're going to learn not to respond to

46:38that hunger. You're going to hold your

46:40fast. And we see from the research that

46:42women who do that end up craving more

46:44simple carbohydrates in the afternoon

46:46moving incidentally less and

46:48contributing to poor sleep because

46:50they've now phase shifted. So when we're

46:52talking about sleep and how important

46:54sleep is, we also have to think about

46:55the circadian rhythm and how it is

46:57affected by food intake, light,

47:00darkness, and all of the things. And we

47:02need women to understand we want to

47:03build muscle. We want to sleep well and

47:05that requires food. Well, and it this

47:08goes back this whole thing you just said

47:10goes back to very early in this

47:13conversation where I was talking about

47:17sometimes we like to focus on the bright

47:19shiny gadgets

47:20>> when we haven't taken our health from

47:23fine to optimize because everything you

47:27just talked about

47:29>> it isn't a gadget it's basic lifestyle

47:33>> in the medical model of PCOS when I'm

47:36talking about what we're taught and how

47:39we train our clinicians.

47:42We go into the, you know, we we aren't

47:44taught a lot about disease prevention or

47:46and I hate to use the term root cause

47:48because I think it's been usurped by

47:49certain members of, you know, the

47:51wellness community.

47:52>> Take it back.

47:52>> Yeah, we're going to take it back. And

47:54so, especially for PCOS, I was taught to

47:57give a patient birth control pills or

47:58Clomid when she's ready to get pregnant.

48:00And so nothing nothing around nutrition,

48:05exercise, lowering inflammation and I

48:07was a program director until 2018 and

48:10there was nothing in the curriculum

48:12around this which affects at least 10%

48:15of women probably more this condition

48:18that how important lifestyle is. You

48:21know, she went on for 10 minutes about

48:23all the lifestyle change, which is

48:25amazing.

48:25>> Which is amazing.

48:26>> But but patients,

48:27>> but I'm sitting there thinking birth

48:28control pills, birth control pills. I

48:30mean, that was a knee-jerk reaction. I

48:31mean, I was treated for my own

48:33polycystic ovarian syndrome for 20 years

48:36with oral contraceptive agents. And I

48:39learned online through chat rooms about

48:42the nutrition end of it.

48:45>> Yeah. when I have athletes because we

48:47see a higher percentage of PCOS in

48:49successful female athletes.

48:51>> Why

48:51>> like what do I do? And it's looking at

48:54what kind of training they're doing. So,

48:56we're putting this more short, sharp,

48:58high intensity to get that post exercise

49:00response of anti-inflammatory,

49:03growth hormone response, all of these

49:05things that then bring down total body

49:07inflammation. And then we're very

49:09careful about food intake and when we're

49:11doing it and what kinds of food so that

49:14they don't have to go down the route of

49:16oral contraceptive pills because that to

49:19them has an effect on their performance.

49:20When we're talking about the top end and

49:22when we bring it back down into

49:24recreational female athletes, we can do

49:26the same thing. It's just we have to

49:27educate and say these are our lifestyle

49:29choices and then these are our medical

49:32choices and what's optimal for your life

49:34at this point. Mhm.

49:35>> It's important to say at this table, and

49:37we all talked about it last night, you

49:40need to have a period if you're not

49:41preventing a period with hormonal

49:43contraception and you're in your

49:44reproductive years. Because very often

49:47women with PCOS or hypothalamic

49:50amenorhea will say, I don't have a

49:52period, but I didn't really like that

49:54anyway, so it doesn't bother me, right?

49:56How many women have said, well, I didn't

49:57get my period for a year, but that was

49:59fine by me. But that's not fine by your

50:02body. That is hypoestrogenic time. It is

50:05low estrogen.

50:06>> Yeah. Very low estrogen. It's bad for

50:08your body on so many reasons to be low

50:11estrogen during these crucial bone

50:13building years. But for we're talking

50:15about how your hormones communicate

50:16back. It's very harmful to long-term

50:18health to have low estrogen

50:22at all.

50:22>> Brain health.

50:23>> But yeah, but especially in young years

50:26when you're still developing.

50:28>> Why would a woman say that she didn't

50:30want to have her period? I mean, this is

50:31a super naive question as a guy, but I

50:32understand it's painful.

50:33>> I mean, do you want to bleed from

50:34>> Do you want that?

50:35>> I mean, if it was a choice now,

50:37>> actually knowing now what I know now

50:41>> and for my own young daughters, I'm

50:42like, we have got to make sure you have

50:44a period. But when I was young, I was a

50:47dancer and an athlete. I had very low

50:50body fat and I wouldn't have periods for

50:526 to9 months. And I'm like, yes.

50:54>> Do you know what's interesting? I was

50:55thinking of Mel.

50:58She because of what she's been through

51:00and also because she's listened to the

51:02conversations I've had with all of you

51:04and she understands the value and

51:06importance of her period, she now

51:08celebrates it. It's like a celebration

51:10in our house when it arrives because

51:12>> because if you understand the importance

51:13that it has in sort of full body health

51:15and the role it's playing, then the

51:18pain, the downside

51:20>> is weighted against your understanding

51:22of the upside, which to her means she's

51:24healthy, she's fat,

51:25>> hormonal health is working, things are

51:26great. And that's the conversation shift

51:29that I'm hoping is gonna instead of

51:31being a detriment and a downer and

51:32talked about she must be on whatever

51:34derogatory yes derogatory things are

51:37said about us that oh my gosh she is so

51:40healthy.

51:41>> Yeah. I remember sitting in a high

51:44performance meeting just maybe three

51:46years ago and the leading athletics

51:48coach stood up and said I know when my

51:50athletes are ready to perform on the

51:52world stage when their periods stop. And

51:54all of us went what?

51:57It's like no, that's the time where like

52:00we have to really look at your athlete

52:02is getting ready to crack and be

52:03injured.

52:04>> And it's still this pervasive idea and

52:07it's still pervasive even in the fitness

52:09industry that losing your period is okay

52:12cuz that means you're training harder.

52:13>> They actually are very resistant to

52:15getting it back.

52:15>> Yes. Like it's a sign of failure of

52:18their sport or their athletic endeavor

52:20because this is is so pervasive. And I

52:22think that's why it's important to have

52:24these discussions. And I love hearing

52:26that Mel now says, "Yay, my period is

52:28here." Because that's a sign of hormonal

52:30health and things are working well

52:32because that is how we should feel. But

52:34I think the other part of it is for

52:36women who have mayoria or heavy bleeding

52:39and heavy cramping. They don't realize

52:41that they can get help with that as

52:43well. Mhm.

52:43>> And that's a conversation that isn't

52:45followed through when we're like, "Yes,

52:46get your period, but if you're someone

52:48who suffers from really bad cramps, we

52:50also have to educate that there are

52:51things that we can do to help with that.

52:53>> Does the size of the bleed matter?"

52:56Because she turned around to me the

52:57other day and she said with her last

52:59cycle, she said that she didn't bleed

53:00much and she seemed slightly concerned.

53:02Obviously, I had no idea what to say to

53:04that.

53:04>> It depends.

53:05>> Congratulations. Well done. I'm so

53:06sorry. minora. So we have definitions

53:09and there are you know we don't walk

53:10around with measuring cups generally

53:12between our legs to measure how much

53:14blood's coming out each month. But

53:15>> but women know

53:16>> but women know your period should not

53:18cause you with modern you know period

53:22products your cycle shouldn't cause you

53:25any stress in your life. You should just

53:27roll with it, right? And so that's when

53:29I'm like when is it a problem?

53:30>> Shouldn't bleed through your clothes.

53:31>> You should be able to sleep through the

53:32night. You should be able to get through

53:34an athletic performance. You should be

53:35able to do X, Y, and Z. Now when we do

53:38start measuring and you should not be

53:40anemic. So I'm not waiting till anemia.

53:43I am anemia is low red blood cell count

53:46you know to the point where your

53:48performance is affected. Your ability to

53:50carry oxygen is effective. So the red

53:51blood cells are what carries oxygen in

53:56our bodies. And women who have heavy

53:59periods however that's defined can lead

54:02to anemia. But the first thing that we

54:04notice is their feritin is dropping.

54:06That's the first sign my do my daughter

54:08we just had some blood work done. She

54:09was feeling a little fatigued and her

54:11ferotin and iron saturations were really

54:13low and I was like talk to me about your

54:14period. Turns out she's not eating a lot

54:16of iron rich foods. So we're dealing

54:17with that. But you know we can get so

54:19far ahead of this and looking at these

54:22ferotin levels the transfer you know

54:24these iron studies before she's actually

54:26anemic which is like the last thing that

54:28happens when her red blood cell count

54:30drops or they become so small and what

54:32we call microitic. you know, we are we

54:35need to do a better job at recognizing

54:37these things. We're not going to walk

54:38around and measure how much blood's

54:40coming out because I could maybe squeak

54:42out 200 cc's, you know, a period and you

54:45could be 300 and we're both doing fine.

54:47You know, we both have great. So, I

54:48think it's really looking at, you know,

54:50how much bleeding is too much. Now, how

54:52little is too much? That that's probably

54:54better in your

54:55>> Yeah. Is any change from what you

54:57consider normal? We would all say this

54:58is a normal amount. So if it gets

54:59heavier than that or less than that and

55:02it stays that way, that is concerning.

55:04You can always have a one-off. Estrogen

55:06is the driver of growing the uterine

55:08lining. So if you have a lighter bleed

55:11one month, we are concerned that you did

55:13not grow as thick of a lining. Your body

55:15didn't see as much estrogen. Most the

55:17time you ovulated earlier that cycle,

55:19your cycle came a little bit sooner than

55:21you're used to it coming, and it's not

55:23quite a big deal. But this can be

55:26concerning if we see consistently light

55:28periods, especially if we have history

55:31of progesterone contraception, which

55:33progesterone thins out the lining and

55:35estrogen grows it. So progesterone

55:38actually stabilizes it, but for the sake

55:39of the discussion, we'll say estrogen

55:41grows it, progesterone thins it. When

55:44you only see progesterone, like a

55:45progesterone IUD, the progesterone shot,

55:48even continuous birth control pills,

55:50because they give you a type of

55:52synthetic estrogen and progesterone

55:54every day, your uterine lining gets

55:57thinner and thinner and thinner. And so

56:00we see it can take months to return to

56:02normal after coming off of hormonal

56:04contraception. You also can get damage

56:07to the endometrial lining. There's stem

56:09cells in the endometrium that regenerate

56:11every month after you bleed. They

56:14regenerate so that the next group can

56:16grow in response to estrogen. And this

56:18can get damaged from typically anything

56:21inside the uterus. So most commonly this

56:24is post birth, you know, a traumatic

56:26birth, a retained placenta, a DNC

56:29procedure, which is sometimes used after

56:31birth or in a miscarriage or even IUDs

56:34or intrauterine surgery. and it can form

56:36scar tissue in the uterus that can cause

56:38a light period. So if you said, "Oh, Mel

56:42had a miscarriage and had this procedure

56:44and now her periods are lighter." I'm

56:45highly concerned.

56:47>> Versus amen.

56:48>> Yeah. So that is concerning for scar

56:50tissue in the uterus.

56:51>> Okay.

56:52>> If you said, "Oh, she was on a birth

56:55control pill for a while and now it's a

56:57little bit lighter." I'm less concerned

56:58that's probably going to get better. or

57:00if this period came closer together

57:02>> or if you traveled around the world

57:04three times this last month or

57:06>> so one one off is no big deal but a

57:09change from your baseline can be

57:11concerning in addition we should say

57:12that that graph is beautiful but you

57:15know your thyroid your pituitary gland

57:17it makes prolactin prolactin also

57:19changes the endometrium so there's

57:21subtle signs of other hormonal issues

57:24that your menstrual cycle is the first

57:26warning sign that something is off

57:28>> what about pain She 2 months ago she had

57:31like excruciating pain that I've never

57:32seen before during her menstrual cycle.

57:35>> Well, it's not pleasant to have your

57:37uterus contract and expel its contents

57:40in any form.

57:41>> But what if it's like way above the

57:43norm?

57:44>> One time way above the norm is probably

57:46situational based on other things that

57:48are contributing to inflammatory burden

57:51or response. your body is also healing

57:53from a the corpus ludium's a cyst on

57:55your ovary that can also feel painful

57:57and at the time of your period it is

57:59also healing so there's multiple things

58:01that can cause pain

58:04to Vonda's point so many people say I

58:06have a high pain tolerance this is okay

58:09because we don't talk about our own pain

58:11so I don't know if my pain is normal

58:13compared to somebody else's your pain

58:16should not keep you out of your

58:18activities of daily living you shouldn't

58:20call in sick to school call in sick to

58:22work, cancel dinner plans with friends

58:25consistently. Again, everybody can have

58:27a one-off month where something is off.

58:29But if this happens every month, oh,

58:31it's my period. I'm going to cancel

58:32that. That is a warning sign that

58:35something else could be going on.

58:36Endometriosis, adnomiiosis, and uterine

58:39fibroids.

58:39>> You mentioned the word iron a second

58:41ago, Dr. Mary. What is iron got to do

58:45with this? And what is iron? So iron is

58:47an element that is in our diets and we

58:50do tend to store quite a bit of iron in

58:52our bodies and it's an essential when we

58:54look at the structure of the red blood

58:55cell and of hemoglobin specifically. So

58:58hemoglobin is the actual molecule that

59:00is inside of the red blood cell that

59:02carries the oxygen. So iron is really

59:04critical to the formation of healthy you

59:08know iron carrying red blood cells and

59:10we we store iron in our bodies and so

59:13and a lot in the bone marrow and in and

59:16it's stored in this particular molecule

59:18called feritin. So when we're measuring

59:20ferotin levels in the blood that is you

59:24know the first sign that your iron

59:25stores are getting low is when we see

59:27these low feritin levels. Are women more

59:30iron deficient than one would think?

59:33Like is the general population iron

59:35deficient or what do you tend to see

59:37when you run lab tests?

59:39>> A menstruating woman. Yes.

59:40>> A menstruating woman is is often

59:43iron deficient.

59:44>> Yes. And I we I do see it in our post

59:46post-menopausal patients as well. That's

59:48usually nutritional and inflammation

59:51related. So ferotin is also something

59:54that will decrease in in times of

59:56chronic inflammation. And so you're not

59:57able to utilize the iron that's coming

59:59in and store it because this

1:00:00inflammatory state is kind of inhibiting

1:00:02that. So in a menstruating patient, I'm

1:00:05always thinking is she bleeding too much

1:00:07the first time, you know, and is that

1:00:08bleeding menstrual? Is it coming from

1:00:09her rectum? Is it coming from her

1:00:11gastrointestinal tract? You know, does

1:00:13she have gastritis or, you know, we have

1:00:14to go through the, you know, the

1:00:16algorithm of why that might happen. In a

1:00:18post-menopausal patient, we can remove

1:00:20vaginal bleeding from the issue, you

1:00:22know, uterine bleeding, a period, but

1:00:24then now I'm looking at nutrition. And

1:00:26I'm looking at exercise. I'm looking at

1:00:27inflammation as causitive factors.

1:00:29>> And the global pitch here is the World

1:00:30Health Organization estimates that

1:00:32roughly 30% of women aged 15 to 49

1:00:34worldwide are anemic with iron

1:00:36deficiency being the leading cause. And

1:00:38in some reason regions of South Asia and

1:00:40subsaharan Africa prevalence can be up

1:00:42to 50% of women are anemic with iron

1:00:46deficiency being the leading cause. H

1:00:49>> you noticed the norms have changed.

1:00:52>> So it depends on who you read.

1:00:54>> Yeah. again, you know, when you're

1:00:55looking at male male normative curves

1:00:57versus what you know, we're we're tend

1:01:00to accept lower levels for a female. But

1:01:02now that we're looking at performance

1:01:04and, you know, looking at other factors

1:01:07besides just what is this feritin level,

1:01:10>> um there's a lot great new research

1:01:12coming out that we are looking at this

1:01:14differently and that that we're in our

1:01:16clinic, we are looking for 60 to 100 for

1:01:18a feritin level to be considered

1:01:20optimal. very different than, you know,

1:01:23the baseline for, you know, keeping you

1:01:27out of out of a hospital versus you

1:01:30functioning at your absolute best.

1:01:32>> Yeah. Because the norms that often get

1:01:34measured for us

1:01:37>> because they tripled, right? They were

1:01:3815 and then they went up to to 40.

1:01:40>> So now they're saying 20 and above is

1:01:43normal. And when I look at a lot of

1:01:45women who are sitting 20 to 30, they

1:01:48can't get help.

1:01:49>> They cannot get help. And it's like,

1:01:51whoa, it was maybe four or five years

1:01:53ago. If you were below 50, then we would

1:01:56look to get help. But now with the norms

1:01:58that have shifted with the sicker

1:02:00population,

1:02:02we can't get women help unless they are

1:02:04below 20. So when we say normal, I think

1:02:07this is important for everybody watching

1:02:09or listening. Normal in medicine means

1:02:12common,

1:02:14>> not non-pathological,

1:02:16>> okay?

1:02:16>> Not bad, you know, doesn't mean it's not

1:02:18bad. And so norms shifting meaning we're

1:02:21getting sicker as a population and we're

1:02:24willing to accept lower levels although

1:02:26they're not optimal for health. The lab

1:02:29reference range what they say when you

1:02:30get your blood work drawn and you see

1:02:31the reference range is based on

1:02:34population averages. And so if the

1:02:36population is more anemic this is going

1:02:39to accept a lower levels being normal

1:02:43even though they're by no means optimal.

1:02:45And I think that's one thing we all talk

1:02:48about is well how are you feeling your

1:02:50symptomology? What do we see? And you

1:02:52have to interpret blood work in context

1:02:54of the whole person and what is

1:02:56happening. And that is one issue we do

1:02:58see with getting your own blood work

1:03:00drawn or these online companies when

1:03:02nobody's interpreting it or helping you

1:03:04interpret it on the other end. You see

1:03:06something that is in a normal range but

1:03:09it's not at all optimal for you and it

1:03:11could be the reason why insurance. Yeah,

1:03:13exactly. I want to talk about

1:03:14endometriosis. I we have a team member

1:03:16who's been with the Davosio since the

1:03:18very beginning called Liv.

1:03:19>> Yes.

1:03:20>> Are you familiar with Liv?

1:03:21>> I am.

1:03:22>> So at age 13, she had her first period

1:03:24and she experienced agonizing pain with

1:03:25heavy bleeding.

1:03:27>> At age 14, she was put on the pill to

1:03:29manage the symptoms. Between age 15 and

1:03:3224, she continued to have severe stomach

1:03:34pain which resulted in multiple A&E

1:03:37visits. She was often dismissed as

1:03:40having gastriisitis.

1:03:42>> Mhm. And it led to having her appendix

1:03:44removed.

1:03:45>> Oh my god.

1:03:47>> Why'd you say oh my god

1:03:48>> can get surgery?

1:03:50>> But she had major surgery and

1:03:54>> um I' I've seen this course before and

1:03:57it's it's devastating cuz she's going

1:03:59years and years and years now of

1:04:01>> Yeah. age 25 she came off the pill to

1:04:04see how she felt without it but her

1:04:06periods worsened and she fainted from

1:04:07the pain. So she went to accident and

1:04:09emergency. At age 26, she got an

1:04:11ultrasound which suggested

1:04:13endometriosis, but no NHS diagnosis was

1:04:16given.

1:04:18We ultimately had a conversation with

1:04:20you on the podcast, Natalie, and she

1:04:22felt very heard and she was actually

1:04:24there. And so afterwards, Jamaima in the

1:04:26team, who you you guys know, um told Liv

1:04:29to come and speak to me. And Liv told me

1:04:31after you left about um the symptoms,

1:04:34did she speak directly to you at that

1:04:36time? She did. Okay. So, she came and

1:04:37she spoke to us about her endometriosis,

1:04:39which is the first time I'd ever heard

1:04:40of it. Um, and then we offered to help

1:04:44support her privately so she could get

1:04:45private support with it. Um, and she got

1:04:49an MRI scan privately, which confirmed

1:04:50stage 4 infiltrating endometriosis.

1:04:53>> Oh gosh.

1:04:55>> Liv then pushed um on with her NHS

1:04:58appointments, the National Health

1:04:59Service in the UK, but the pain was so

1:05:01much that she took me up on my offer to

1:05:04pay for it privately. So, we paid for it

1:05:06privately. Uh, and the endometriosis by

1:05:08that point had spread to her bowels and

1:05:09pelvis. And I've got this picture of

1:05:11this four cm cyst. If you're all

1:05:14faint-hearted, I mean, I don't know

1:05:15where we'll put this on the screen, but

1:05:17this is from her operation.

1:05:18>> Yeah. It's called an endometrioma. It's

1:05:20huge.

1:05:21>> For anyone that can't see, it kind of

1:05:23looks like a tumor.

1:05:24>> Yeah.

1:05:25>> Um, next to her ovaries

1:05:28>> and it had spread at that point to her

1:05:30bow and pis pelvis. It had become about

1:05:324 cm big. Her ovaries were stuck

1:05:34together and attached to her womb and

1:05:36her bowels. She then needed to book an

1:05:38appointment for surgery. And before the

1:05:40surgery, because of the scale of her

1:05:41endometriosis, she had her eggs frozen

1:05:43to protect her future fertility, which I

1:05:45guess came from your advice. This

1:05:47process took her 7 years and she was in

1:05:50pain for 17 years because she did not

1:05:53get a diagnosis.

1:05:55>> Her story is unfortunately not uncommon.

1:05:58This is a very typical story for

1:06:01somebody who suffers from endometriosis.

1:06:04Endometriosis is an inflammatory

1:06:07condition. And the way I like to explain

1:06:09it is when your body responds abnormally

1:06:11to a normal process. You have immune

1:06:13dysfunction as well. So let's think of

1:06:14it as an autoimmune disease and a

1:06:16chronic inflammatory disease. When you

1:06:19have your period, you bleed out

1:06:20indometrial cells in your menstrual

1:06:22blood. We're used to that. In everybody,

1:06:24you also have some indometrial cells

1:06:26that will escape out the fallopian

1:06:27tubes. That's not a big deal. If you

1:06:28take out somebody's appendix while

1:06:30they're on their period, you'll actually

1:06:31see menstrual blood in their abdominal

1:06:33cavity. In the regular person without

1:06:35endo, your body says, "Oh, she's just on

1:06:39her period." In the person who has

1:06:40endometriosis, this creates a huge

1:06:43inflammatory response where your body

1:06:45starts to attack indometrial cells and

1:06:48you get these implants throughout the

1:06:50what's called the peritineal cavity or

1:06:51the abdominal cavity of indometriallike

1:06:54tissue that gets worse every time your

1:06:56body sees estrogen which because it's

1:06:59feeding the endometrium just like it

1:07:01would in the uterus and so it gets worse

1:07:04over time. The more ovulatory cycles you

1:07:06have the disease gets worse. It's so

1:07:09inflammatory that it's not uncommon to

1:07:11get extensive

1:07:13organ scarring. You get anatomical

1:07:16distortion. These are some of the

1:07:18toughest surgical cases in addition to

1:07:22managing lifelong health but also

1:07:24fertility as well.

1:07:25>> Just obliterate the anatomy like because

1:07:27the infiltration you'll these implants

1:07:29will start growing into other organs

1:07:31because they'll find new blood supply.

1:07:33They'll steal blood, you know, blood

1:07:35supply from from the bowel from because

1:07:37all of our pelvic organs are just

1:07:39sitting there on top of each other, the

1:07:40bladder, the bowel, the c, you know, and

1:07:43so

1:07:44>> it sounds like it's alive, like it's a

1:07:45cancer or something.

1:07:46>> Think of it like velcro is what I say

1:07:47almost these little patches of velcro

1:07:49and they just start sticking together.

1:07:50And that's what inflammation and

1:07:52scarring does throughout your whole

1:07:53body. And what happens here is that

1:07:57because the primary symptoms of

1:07:58endometriosis is pain. So again, back to

1:08:02women's pain being taken seriously.

1:08:05>> That's one of the issues and why the

1:08:07average time to diagnosis is 7 to 10

1:08:10years. Truly 17 years in this case from

1:08:12when she had pain.

1:08:14>> But the other symptoms do include

1:08:15sometimes also pain with intercourse.

1:08:18Typically though, that is very hard to

1:08:21ascertain from somebody, but it's

1:08:23usually with certain positions. Deep

1:08:25penetration tends to be what really

1:08:27stimulates pain. But you also see a lot

1:08:29of GI manifestations that we don't talk

1:08:31about. So if I have somebody who has

1:08:32painful periods and they say they have

1:08:34irritable bowel syndrome or a lot of

1:08:37vague GI complaints,

1:08:39that is a really big red flag to me

1:08:42because like you said, these little

1:08:44indometrial implants on the bowel, the

1:08:45intestine, this high inflammation that's

1:08:48happening irritates your intestine and

1:08:50you get this GI response as well. One of

1:08:53the hardest things about indometriosis

1:08:55is that it's a surgical diagnosis only.

1:08:58To be honest, we can means

1:09:00>> have to do surgery to fully see and

1:09:03diagnose that you have this.

1:09:04>> It's one of those no meat, no treat, you

1:09:06know, in in in medicine where you can't

1:09:08make the diagnosis until you have a

1:09:10tissue sample. So meat means you go and

1:09:12take a biopsy.

1:09:13>> Okay. See? Okay.

1:09:14>> So you can suspect it based on imaging.

1:09:17We're not great at this. And Dr.

1:09:19Crawford, why don't we have a cure?

1:09:21>> Mhm. Well, because it hasn't been

1:09:23studied is one of is the primary answer.

1:09:26Uh the secondary answer is that often

1:09:29the the goals are tough with endo

1:09:31because if estrogen feeds it, we all are

1:09:34going to sit at this table and talk

1:09:35about how important estrogen is for your

1:09:37body. And a a lot of the treatments that

1:09:39exist for endometriosis take estrogen

1:09:42away to try to not feed these lesions.

1:09:44And that has a slew of other symptoms

1:09:47and long-term health implications as

1:09:48well. Truly, we don't even give women

1:09:54options to try to feel better. They are

1:09:57given birth control pills because, hey,

1:09:59I'm going to stop the ovulatory cycle.

1:10:01I'm going to you're going to have less

1:10:03what we call unopposed estrogen days.

1:10:04>> We do have symptomatic relief.

1:10:06>> Yeah. But we have and that's going to

1:10:07help hopefully with some of your

1:10:08symptoms. And it can for some women. It

1:10:11doesn't reverse disease. It doesn't cure

1:10:13it. It doesn't make anything better, but

1:10:15it can slow down the progression any of

1:10:18these treatments that do halt the

1:10:21ovulatory process, but it severely

1:10:23impacts I mean beyond so many layers of

1:10:26your your mental your emotional health,

1:10:28your relationships, but your fertility.

1:10:30Stage three or four disease, regardless

1:10:33of your age, you're going to have a less

1:10:34than a 20% chance of conceiving

1:10:36naturally over the course of your life

1:10:38if you have stage three or four disease.

1:10:40Every stage is impactful to your

1:10:41fertility because of the inflammation.

1:10:43Once you have anatomical distortion, an

1:10:45indometrium or cyst inside the ovary,

1:10:48removing that cyst is going to decrease

1:10:50your egg count. That that's going to

1:10:52have a major implication on your

1:10:54potential. That's why we froze eggs

1:10:57before we to cyst out so that we could

1:10:58get those eggs, at least some that we

1:11:00could out of the body before we went and

1:11:02did something that was going to destroy

1:11:04part of the ovarian tissue. What you

1:11:07said, Stephen, is it seems like

1:11:08indometriosis is alive. And that's a

1:11:10really great analogy because it does

1:11:12just feed into tissue and it's highly

1:11:15destructive and if it distorts the

1:11:18anatomy, we need a healthy floppy

1:11:21fallopian tube generally that can swing

1:11:23around and pick up this egg that's

1:11:25floating around our abdominal cavity for

1:11:27and then you need a place for the egg

1:11:29and sperm to meet which is generally a

1:11:31healthy non-inflamed fallopian tube. So

1:11:33they're also at increased risk for

1:11:35infertility but ectopic pregnancies.

1:11:37That's where I see them, you know, is

1:11:39when I was a hospitalist is in the O,

1:11:42you know, emerently from a ruptured

1:11:44fallopian tube from this, you know, and

1:11:46I go in and I'm making not only she's

1:11:48lost a wanted pregnancy now I and I'm

1:11:51making the diagnosis of indometriosis at

1:11:53the same time and they are just

1:11:54devastated. I just feel sitting here not

1:11:57being anywhere within this field

1:11:59thinking wait a minute because I was a

1:12:00cancer nurse first right before I did

1:12:02this wait a minute there's got to be a

1:12:05cell surface marker that's unique to the

1:12:07endometrium that we could make a

1:12:09monoconal antibbody against

1:12:11>> there's got to be a cell surface marker

1:12:13and I will say that there are people now

1:12:15doing lovely and wonderful research on a

1:12:17cellular level of indometriosis trying

1:12:20to look at the endometrium itself what

1:12:22cell markers are similar in indometrial

1:12:24implants

1:12:25Can you diagnose this on an endometrial

1:12:28biopsy in somebody?

1:12:30>> We haven't seen it get to the point

1:12:32where it needs to, but at least people

1:12:34are paying attention. So, I do think we

1:12:37might have emergent technology that will

1:12:39change the course of this for people.

1:12:41>> Right now, I think awareness is key. And

1:12:44one thing I always say is that

1:12:45especially as a teenager because women

1:12:48adjust. You accommodate to the world

1:12:51around you. That's one of the things

1:12:52that I think makes women so resilient. I

1:12:55mean, if you have pain every single

1:12:56month of your life, you are going to

1:12:58convince yourself this is normal for a

1:13:00degree of time because what other option

1:13:01do you have? Has to get so bad. But when

1:13:05you're a teenager, you don't know that.

1:13:07And so, if when you are a teen, you

1:13:09would stay home from school, you would

1:13:11not go to the football game or go out to

1:13:13dinner with friends, that to me has is a

1:13:17huge red flag. But it actually is a very

1:13:19high predictive marker that you do have

1:13:21indometriosis.

1:13:23So pain out of proportion to being able

1:13:25to complete your normal life as a

1:13:28teenager is a really big warning flag. I

1:13:30ask every patient about that when we

1:13:31talk about their periods because 50% of

1:13:34patients with unexplained infertility

1:13:36have indometriosis.

1:13:37It is so hard to diagnose and

1:13:39underdiagnosed yet impactful to our

1:13:42body.

1:13:43>> 26 years old. The advice given to her by

1:13:45the NHS was to go back on the pill to

1:13:49solve for the the pains that she was

1:13:51getting. We certainly have a lot of

1:13:53dismissive doctors and people who don't

1:13:55take pain seriously, but also a disease

1:13:57that is underfunded and not researched.

1:13:59We do have limited options for how you

1:14:02can help somebody. And I think we have

1:14:04to acknowledge that both things can be

1:14:05right. Now, getting to the root cause of

1:14:08your pain is always going to be really

1:14:10important versus just saying here's a

1:14:12birth control pill that should take care

1:14:14of it. Some women with endometriosis

1:14:16love being on the birth control pill.

1:14:18does highly improve their symptom

1:14:20profile and it's an important part of

1:14:22their treatment regimen. Other women do

1:14:24not find any benefit from it and it's

1:14:26really important to have the discussion

1:14:28especially with indometriosis in regards

1:14:30to your family planning goals. Do you

1:14:32want kids? When is that going to be?

1:14:35What might this look like? Because we

1:14:37know if you have a higher rate of

1:14:38infertility, a higher rate of needing

1:14:40IVF, do we need to intervene sooner? But

1:14:43that's going to impact some of the

1:14:44treatment options we're able to give you

1:14:46because some of them do delay ovulation

1:14:48from for a prolonged period of time.

1:14:50>> What I find in the patients, you know,

1:14:52when we made the diagnosis was they're

1:14:54forced into making these kind of

1:14:56life-changing decisions about around

1:14:58their fertility and ability to conceive

1:15:01before they were ever before their peers

1:15:04were even thinking about it. It's pretty

1:15:06devastating.

1:15:08>> It is. We have some pilot data looking

1:15:10at taking some of the nuances of

1:15:12recovery and looking at how to dampen

1:15:15inflammation. So we have some pilot data

1:15:18that's showing when women do cold

1:15:20exposure

1:15:21>> that it dampens inflammation and

1:15:23improves their symptomology. So I'm

1:15:26always thinking on the outside like what

1:15:27other things can we do to dampen

1:15:30inflammation in a positive way to

1:15:32improve symptomology.

1:15:34>> How does that work? So, if we're

1:15:36thinking about the responses to cold

1:15:39exposure, and we're not talking about

1:15:40ice, we're talking about cold water

1:15:42exposure. It creates a cascade of immune

1:15:46responses that kind of protects the

1:15:49body. So, we're reducing inflammation,

1:15:51we're improving parasympathetic, which

1:15:53reduces stress. Mhm.

1:15:54>> So, if we're timing it and they know

1:15:56when their period is and they can go,

1:15:59okay, well, for the next or the 10 to 14

1:16:02days before my period starts, I'm going

1:16:04to have 10 minutes of cold water

1:16:06exposure. And over the course of 3 to 4

1:16:09months, that immune response becomes

1:16:12learned. So, it reduces symptomology.

1:16:15So, it becomes one of the treatment

1:16:16options that we have for some of our

1:16:19athletes that have endo and interferes

1:16:21with their training. Mhm.

1:16:22>> So I mean the cold water exposure is

1:16:24available there. So that's how we

1:16:26started the pilot study.

1:16:28>> Um trying someone wanted to do this at

1:16:30home.

1:16:30>> 10° C. So what is that about

1:16:34>> 40? Yeah. It feels really cold but not

1:16:37an ice bath.

1:16:37>> Not an ice bath because ice is

1:16:39>> Ice is not good for

1:16:40>> Can you get that in the shower?

1:16:42>> You you need to

1:16:43>> This is like cold submersion.

1:16:45>> Can you do that at a home tub just with

1:16:46turning on the spigot?

1:16:48>> You could if you get really cold. Yeah.

1:16:49You might want to add a little bit of

1:16:51ice and let it melt. Okay.

1:16:52>> But um not ice baths that we see in all

1:16:55the popular media because that is way

1:16:57too cold for a woman's body. It does the

1:16:59opposite. It's a severe stress and

1:17:02causes a stress response rather than a

1:17:04parasympathetic calming response that we

1:17:06want.

1:17:07>> Okay. Like Stacy said, decreasing

1:17:09inflammation in an inflammatory disease

1:17:11is key to controlling the factors you

1:17:13can. And much like we talked about

1:17:15inflammation and PCOS, we heard the same

1:17:17word right here with endometriosis.

1:17:20Chronic inflammatory diseases are the

1:17:22number one thing that we see across the

1:17:23board impacting the population but

1:17:26especially women.

1:17:28>> And so these same strategies to work on

1:17:30decreasing your own inflammation

1:17:33>> and for endo it's a little different

1:17:35because you can target it for when you

1:17:38expect to have that high inflammatory

1:17:40burden. But that's really an important

1:17:42part that we don't talk about. I don't

1:17:43see that the NHS talked about an

1:17:45anti-inflammatory diet or getting more

1:17:48sleep or cold exposure.

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1:18:54Now, on this point of birth control, one

1:18:57of the questions that came in from the

1:18:58audience was, "How terrible is birth

1:19:00control to female hormones?"

1:19:03The birth control pill shuts off the

1:19:06brain's desire to send the signal to the

1:19:08ovary to make hormones. So, it is

1:19:10ethanol estradiol, a synthetic estrogen,

1:19:13and a type of a synthetic progesterine

1:19:15or progesterone. These work, the brain

1:19:18thinks that you have estrogen and

1:19:20progesterone present. As we said, that's

1:19:22the ludial phase. And so, your brain

1:19:25says we don't need an egg to grow.

1:19:26>> Ovulation starts in the brain. Y, right?

1:19:28>> So, no FSH comes out and you're not

1:19:31going to get ovulation. So they're very

1:19:32effective for prevention of ovulation

1:19:35which is makes it a very effective

1:19:37contraceptive option. But as far as hor

1:19:40hormonal shifts, yeah, your brain's not

1:19:42sending out FSH and LH. Your ovaries are

1:19:44not going to be making estradiol or

1:19:46progesterone

1:19:47>> or testosterone.

1:19:48>> True.

1:19:49>> And so that is how they are sometimes

1:19:51helpful if you have, you know, uh some

1:19:55women get hemorrhagic cysts with

1:19:56ovulation. every every time you ovulate,

1:19:58you when you rupture that cyst, you get

1:20:00a lot of bleeding. The birth control

1:20:02pill can prevent ovulation, therefore

1:20:04prevent some women from being in

1:20:05terrible pain. If you have PCOS, they're

1:20:08often handed out like candy. One reason

1:20:10is because it will regulate your cycle

1:20:12so that you don't have these prolonged

1:20:14irregular periods, but also will

1:20:17decrease testosterone levels, which is

1:20:19sometimes a good side effect of the pill

1:20:21for women who have PCOS,

1:20:23>> back to a normal level.

1:20:24>> Yeah. But if you don't have PCOS or the

1:20:27regular person, a lot of times your

1:20:29body's tissues are not responding to

1:20:31synthetic estrogen and progesterone the

1:20:33same way it does to natural. I think

1:20:34that's a very important point. So my

1:20:36niece who competes uh at a national

1:20:40level and she's 14 started suffering

1:20:43from as she was going through her

1:20:44adolescence her acne got outrageous and

1:20:47she's a 14-year-old girl 13. start at 12

1:20:49and a half. And of course, you know, she

1:20:51goes to the dermatologist and they're

1:20:53trying some topicals. And then finally,

1:20:55as you go down the algorithm for how we

1:20:57treat acne, one of the off label uses is

1:21:00birth control pills will lower the

1:21:02testosterone. Their skin can clear up.

1:21:04So, her father, a little concern, comes

1:21:05to me. Um, her mom passed away. Her

1:21:08stepmom had passed away. So, he didn't

1:21:09have the mom in the house to, you know,

1:21:10the immediate mom to talk to. And for

1:21:14the first time, I immediately thought of

1:21:16her athletic performance. Thank you, Dr.

1:21:18Sims and I thought she wants to go to

1:21:20the Olympics. There's no way I'm going

1:21:23to let her testosterone levels drop.

1:21:24Like, we're going to throw everything

1:21:25topical at this. And we finally found

1:21:27the right combination. Her skin looks

1:21:28great and she's super happy. But like,

1:21:30the next logical thing was to put this

1:21:3214-year-old, you know, on a birth

1:21:34control pill to get her acne under

1:21:36control, which is the end result. But

1:21:38what no one's thinking of is her

1:21:40athletic performance. How is it going to

1:21:42affect her

1:21:44>> training years leading

1:21:45>> and her training years? Like, this is

1:21:46critical for her. 16 is when the next

1:21:48trials are up for her. So that's 2 years

1:21:50from now. So we were able to get her

1:21:52acne under control, avoid the birth

1:21:54control pill, but that was nothing I'd

1:21:56ever thought of before.

1:21:57>> Well, I'm sitting here from a

1:21:59muscularkeeletal standpoint thinking

1:22:02about the high percentage of women who

1:22:05have endometriosis and PCOS and the

1:22:08complete soundingly

1:22:11imbalance of natural hormones. Plus,

1:22:16for a lot of reasons now, girls are not

1:22:20cycling normally.

1:22:21>> Mhm.

1:22:22>> And I'm sitting here terrified for their

1:22:25bones.

1:22:25>> Yep. 100%.

1:22:27>> Because we build bone from 15 to 25.

1:22:32And if we are so inflamed that we're

1:22:35producing all kinds of inflammatory

1:22:36cytoines IG interlucan 6 and uh C

1:22:41reactive protein and tumor necrosis

1:22:43factor which halt bone development we

1:22:46don't have enough estrogen for whatever

1:22:48reason we're going to shut off our

1:22:50testosterone because it makes us feel

1:22:52better

1:22:52>> and we're not exercising

1:22:53>> and we're sitting around.

1:22:56No wonder I have 20 and 30 year olds

1:22:59with no bone density that are then going

1:23:02to go into pmenopause which we will get

1:23:04to and lose another 20%.

1:23:08>> So I was pretty feeling pretty hopeful

1:23:11that the generation Xers are going to

1:23:14get to the millennials and get to the

1:23:16whatever they're called after that.

1:23:18>> It is

1:23:19>> we're gonna be you're gonna see it get

1:23:20worse before it gets better. Exactly.

1:23:22That's what I'm sitting here terrified

1:23:23like. Okay. I thought, okay, baby

1:23:26boomers, those women missed out. Xers,

1:23:30we're doing the best we can.

1:23:32Millennials, but no, cuz now you're

1:23:35telling me our 15 to 25 year olds are

1:23:39still in the same detriment with muscle

1:23:42and bone building.

1:23:44We are trying to change the narrative.

1:23:46That's the group we're trying to target

1:23:48right now. And I do think by educating

1:23:51across the lifespan, we're going to

1:23:53change how those of us who have 11 and

1:23:5612 year olds what we recommend. I I

1:23:59treat girls in their teen years when

1:24:01they come to me without their period

1:24:03much differently than a lot of other

1:24:06people do. But this is learned

1:24:07experience. Instead of just you don't

1:24:09have a period, here's a birth control

1:24:11pill. Say you're not making estrogen and

1:24:13this is a crucial time for you. Let's

1:24:15give you estrogen. Let's talk about why

1:24:17you're not. what can we do to change it?

1:24:20And so this discussion is more than just

1:24:22disease state important like PCOS and

1:24:24endometriosis. It's truly important

1:24:27across the lifespan of a woman. The

1:24:29choices that are being made in her early

1:24:32reproductive timeline is going to impact

1:24:35her longevity.

1:24:36>> Can I ask all of you what you would have

1:24:38done differently

1:24:39>> for ourselves?

1:24:40>> Yeah, for yourselves. Obviously, I know

1:24:42several of you have daughters as well,

1:24:43but what would you have done? I wish

1:24:46everybody could see all of your faces.

1:24:49>> Oh yeah, I've talked about this before.

1:24:51I mean, I was amenoric until I was 20.

1:24:54>> What's amenoric?

1:24:55>> Didn't have periods.

1:24:56>> Okay.

1:24:57>> Because of high stress, high sport, you

1:24:59know, didn't care, didn't eat well in

1:25:02the whole um mindset of the, you know, '

1:25:0490s of calories in, calories out. If

1:25:07you're thinner, then you'll run better.

1:25:09If you're running better, then you're

1:25:11going to hit different metrics. cuz I

1:25:13was a runner in high school and then

1:25:15joined the crew team. Same thing. So, if

1:25:18I could go back and talk to my younger

1:25:19self, I would have been like, "You need

1:25:20to eat, you need to recover, you need to

1:25:22eat, you need to recover." Instead of

1:25:24the mantra of calories in, calories out,

1:25:26more cardio, lose weight, lose weight,

1:25:28lose weight. Because now I educate

1:25:30people is you want to take up space, you

1:25:32want to be strong, you want to look at

1:25:34um not the idea of losing something, but

1:25:36gaining something, gaining that power,

1:25:38gaining that strength, gaining that

1:25:40bone, gaining that muscle, gaining your

1:25:42period. Those are the things that I'm

1:25:44trying to educate the younger generation

1:25:46cuz that was not impressed upon me as a

1:25:49younger athlete, which then had a lot of

1:25:51repercussions later in life. Luckily, my

1:25:54bone density is fine.

1:25:56>> So,

1:25:56>> were you on the contraceptive pill? No,

1:25:58>> you might. Okay.

1:26:00>> I was um not an athlete, so mere mortal.

1:26:04And um

1:26:06uh but it's so you've you've you've been

1:26:08able to take that experience though and

1:26:10apply what you've learned in this this

1:26:11high int, you know, working with these

1:26:14intense athletes to the to the regular,

1:26:16you know, to people who don't exercise

1:26:18at that level. And

1:26:21you know, I completely fell under the

1:26:25the expectation of the aesthetics of it.

1:26:29>> When I did exercise, I exercised to look

1:26:31a certain way. And then in my 30s, I

1:26:34exercised for performance. I started

1:26:36running half marathons. I was doing baby

1:26:38triathlons, really short ones with my

1:26:40girlfriends. It was a social thing and

1:26:41it was super fun. You know, I was

1:26:43running for time. Now I'm exercising for

1:26:46my old lady body. Yep. You know, I'm

1:26:48exercising to be in a bigger body cuz I

1:26:50know my mother and my grandmother. So,

1:26:53my grandmother spent the last 10 years

1:26:54of her life in a bed incontinent with

1:26:57dementia and completely frail.

1:27:01And my mother is on the same course. My

1:27:02mother is 88, fell and broke her hip in

1:27:05January. She just now is walking on a

1:27:08walk or she's in assisted living

1:27:09facility for Alzheimer's.

1:27:11I want to change that legacy for my

1:27:13children. I don't want that to be my

1:27:15path and I don't want my children to

1:27:19have that to be an expectation.

1:27:21So all of the things I would have done

1:27:24differently was

1:27:26I wanted to be thin. Thin was healthy.

1:27:28That is what I learned in medical

1:27:30school. The thinner you were up to

1:27:31starvation, you know, up to you want the

1:27:34lowest body mass index possible without

1:27:38being a little bit too low, you know.

1:27:39And I kind of skirted that line because

1:27:41I stopped eating in medical school due

1:27:42to stress. I would have fed myself. I

1:27:44would have lifted weights. I would have

1:27:46stopped doing so much cardio because

1:27:48knowing I was chipping away at my bone

1:27:50density. I was chipping away. I was

1:27:53raising my inflammation levels. I was

1:27:54chipping away at my ability to resist

1:27:56the Alzheimer's, you know, and dementia

1:27:58that runs in my family. And that's what

1:28:01I'm trying to impress. My girls are 21

1:28:03and 25. What I'm trying trying to

1:28:06impress on them.

1:28:07>> But that's the mentality that we grew up

1:28:09in, right? When you're looking at the

1:28:11supermodels of the '9s and Kate Moss and

1:28:14it was all

1:28:15>> heroin chic.

1:28:15>> Yes, heroin chic, which is the worry now

1:28:17with the GLP1s coming back and the

1:28:21ballerina body and all the things that

1:28:23we're seeing come back again.

1:28:25>> And it's it is worrisome.

1:28:27You know, when I think about I mean,

1:28:29I've already told the world now about

1:28:32having low body fat, maybe being POS and

1:28:35not knowing it, not ever talking about

1:28:37that, having no periods, but then so

1:28:40there was that in my youth that that I

1:28:43would have done better, but that it

1:28:45didn't end in my youth. I mean, I went

1:28:48to college, same. I went to grad school,

1:28:52still same. I went to medical school and

1:28:55in medical school and

1:28:57four years of medical school, seven

1:28:59years of residency and fellowship. Still

1:29:02didn't eat, still wasn't having periods.

1:29:05I didn't sleep for about 11 years,

1:29:07whether between call every third night

1:29:09and then I had a baby and then I was

1:29:11awake for two years cuz she slept with

1:29:13me. That's another discussion. But I

1:29:16think of all these things that I wish I

1:29:18knew then that I know now. I have the

1:29:21same goal. I have four 30-year-old

1:29:24daughters and I have a 17-year-old and

1:29:28they are not going to be allowed to hit

1:29:30a wall like some of us may because we

1:29:33didn't know.

1:29:34>> And were you on the birth control pill?

1:29:37>> You know, intermittently. Uh probably

1:29:39totally in my life about 10 years, but

1:29:44um not continuously.

1:29:47>> And Mary, I forgot to ask, were you on

1:29:49the birth control? Yeah, you were off

1:29:50and on for 20 years.

1:29:53>> So, polycystic ovarian syndrome that was

1:29:55the treatment. I mean, I learned about

1:29:57nutrition kind of on the back end. But

1:30:00the life that I had set up for myself

1:30:02between, you know, medical school,

1:30:04residency, and then going into the field

1:30:07of OBGYn with limited sleep, you know,

1:30:10working 100hour weeks there. I didn't

1:30:13have a environment that would have been

1:30:16conducive to be able to manage that

1:30:17disease

1:30:19with lifestyle

1:30:21and I can look back and say that

1:30:23honestly now

1:30:24>> um

1:30:26with without using the crutch of the

1:30:28birth control pill to manage my

1:30:30symptoms.

1:30:32>> I was on the birth control pill for

1:30:33probably 15 years continuously. And you

1:30:36know, we have to give credit where

1:30:38credit's due because I was able to

1:30:40pursue medical training and not worry

1:30:43about what family building looked like

1:30:46for me, which was really important

1:30:48because I was not ready to have a child.

1:30:51So, anytime we frame a discussion around

1:30:53birth control, I always want to say it's

1:30:55not ever going to fit into one bucket of

1:30:56all good or all bad. It's going to be,

1:30:58you know, different stages of life,

1:30:59different things are important. I didn't

1:31:01stop it soon enough to learn to track my

1:31:03cycle. I didn't recognize cycle

1:31:05abnormalities when I had recurrent

1:31:07miscarriages. I had a really hard time

1:31:09knowing is this how my cycle's supposed

1:31:12to be or not because I never had the

1:31:14opportunity to just have periods and see

1:31:16what is my normal. I stopped it and

1:31:18started trying right away and got into a

1:31:22cycle of having a pregnancy and that

1:31:24would last for a while and then I would

1:31:26lose it. So I really lost the

1:31:28opportunity to say this is my baseline

1:31:30and oh there might be a problem here or

1:31:32to intervene. I wish id advocated more

1:31:34when I had my own pregnancy losses. I

1:31:37was told over and over, there's nothing

1:31:38you can do. This is nothing. Just keep

1:31:40trying. And even as somebody in the

1:31:42field, that felt very dismissive and is

1:31:44a fuel for a lot of what I do now. But

1:31:47on a personal level, you know, 10 years

1:31:48after having those pregnancy losses, I

1:31:51was diagnosed with celiac disease

1:31:54because I had osteopenia on a dexa scam.

1:31:57>> And so I had

1:31:58>> to explain what that is.

1:31:59>> Yeah. So celiac disease is essentially

1:32:01an allergic reaction to gluten. So when

1:32:03I was taking gluten, which is in most of

1:32:05your carbohydrates

1:32:07or the good stuff like breads and

1:32:08pastas, when I was eating those, it was

1:32:11causing an inflammatory reaction inside

1:32:14my body, making my gut unhealthy and

1:32:16kind of creating a baseline level of,

1:32:18let's say, chronic inflammation.

1:32:20>> And recurrent pregnancy loss can be one

1:32:22of the signs and symptoms of it in

1:32:24addition to just some other what feel

1:32:26like very generalized symptoms. fatigue,

1:32:30low energy, headaches, GI distress,

1:32:33>> WW.

1:32:34>> Yeah, I was a whiny woman. And when some

1:32:38of these symptoms finally got to a state

1:32:40where they were getting worse, probably

1:32:41with hormonal change with age, and my

1:32:44doctor ordered a bone scan, and it came

1:32:45back that I had osteopenia, which is

1:32:48very low density of my bones for my age

1:32:51>> and especially at the time, you know, no

1:32:54known medical problems. And so luckily

1:32:56had somebody who was very committed to

1:32:57not labeling me a WW and saying I think

1:33:00you're not absorbing something correctly

1:33:02to get on this pathway to figure out

1:33:04that because of this autoimmune disease

1:33:06celiac disease I wasn't my gut was

1:33:09inflamed. I wasn't be able to absorb the

1:33:10nutrients that I needed.

1:33:12>> But somebody had to be committed on the

1:33:14other end because these symptoms went on

1:33:15for so long. I just accepted them. I let