B (4:26)

I don't even think you know how excited I am. As much as we travel and see each other in different venues, I'm so glad to be in your space.

A (4:34)

I'm so excited. I mean, you're in Dallas, and it's exciting for you to be here in my world in Los Angeles and to see what we're doing in next Health and being on the podcast, and you're such a monumental force in what's happening right now in longevity medicine. It's so. I'm just over the moon that you made it. Thank you.

B (4:53)

Absolutely.

A (4:53)

Yeah. So I know there's a million things we can talk about in longevity medicine, but I feel I've heard you speak very powerfully about perimenopause, menopause, hormone replacement therapy. And I've had this conversation a lot of times. But you bring some new thoughts to the conversation that I don't think a lot of people are talking about. And I want to dive deep on that today.

B (5:15)

Let's dive in.

A (5:16)

All right, so tell us a little bit about you. Like, how did you become. You know, we're all doctors, right? And we're traditionally trained in medicine. And then we decide at some point that we're going to go into this kind of nebulous field of longevity. And I would love to hear kind of your story and how you think about longevity medicine.

B (5:34)

You know, and as when I've heard you speak about your experience, I think that's a big part of a lot of the doctors in the Network of longevity is there's this pivotal moment where you're like, I have to do something different.

A (5:46)

Exactly.

B (5:47)

And that same thing happened to me. You know, I have a background in exercise physiology. That's my, like, claim to fame as far as what I was exposed to early on. And so then going through medical school, obviously you go through the process and how we diagnose disease and how we treat and how we manage patients. And so that obviously is very important. And so that's what we do for years and years. And I did 15 years in academics, which I'm so, so grateful for that opportunity. But at some point, when you start to see patients over and over and over and over again, the story behind why they're seeing you, to me, is more important. And what I found is that the fundamental story that kind of was in all of the patients was much more than why they were sitting there or the disease that got them there. And so when I peel back the layers of. I know that nutrition plays a part. I know that exercise is a fundamental part in how our body's able to show up. And so as you start to unravel or, like, pull the thread, then that's where I started to see that the concept, and it wasn't even called longevity back when I was like, oh, this is a thing, is I needed to impact patients differently. And so when you start to talk to them about these different things, then when longevity, I guess you can say, as a field, came into the scope, I was like, this is where I need to be and that's where I was like, that's where I'm gonna go.

A (7:12)

It's so true. It's almost like the movie the Matrix. And you like living in this virtual world of Western medicine, that everything is supposed to be a certain way. And then you experience a glitch or two in the system and you start unraveling that thread and you realize your mind is blown with how much there's out there that we don't even talk about or even address. And it's really, and it's really rewarding finally when you realize, did you find.

B (7:36)

I found this as well. Because we're like the Matrix. That's like the perfect example of the confines of what you're taught, which are not bad, but it's confined, very confined. Did you find, like dipping your toe out every once in a while? You're like, you feel like a little like, am I the only one? Am I doing something wrong? And then you just keep stepping more of yourself out of it until you're.

A (7:56)

Like, I'm good, 1,000%. In fact, like, you know, you feel like if you look outside the matrix of modern medicine, of, you know, Western medicine, you're almost sometimes shamed or guilted, or you're told you're not practicing evidence based medicine, or you're told you're, you know, you're told so many things that discourages you from getting out of the Matrix. But the minute you do, you realize.

B (8:18)

There'S so much here, there's no going back.

A (8:20)

There's no going back. Exactly. So on the topic of getting out of the Matrix, you know, I think the way Western medicine approaches menopause, I think most people know it's been very confined by studies that were misinterpreted, that were looked at incorrectly. And we have a whole new paradigm now. Right. And could you kind of talk about how you think about menopause, hormone replacement therapy, specifically for women? Right now, let's talk about that and we can expand out from there.

B (8:51)

Let's bring. And I love that you brought that matrix into it. The matrix of what we saw menopause as, how we treated it, how we managed it was based on the WHI, which is 23 years ago, but it wasn't a bad study. But it wasn't for menopause, it was for cardiovascular health. And so from that came, I guess you can say misrepresentation, misinformation, which pretty. If there was a PR for bad information, that was it. And so what we found for 23 years was kind of this conundrum of what do we do with this misinformation? People were running in the streets like it was mayhem. And so we as providers, bringing it back to the provider, really had a lot of fear, because that was the matrix, right? We can't use it. We can't use hormones.

A (9:37)

Black box warnings.

B (9:38)

Black box warnings, which really put a scare factor into everything. And then also, when do we treat women with hormones? Was in a box of. You have to make sure that they've reached menopause. We have to make sure their FSH is elevated. We have to make sure they haven't had a cycle in 12 months. All the while, perimenopausal women, as their hormones are starting to shift and they were having horrible symptoms, you're like, I'm so sorry, you have not reached that deadline of menopause. And so fast forward is, how do we change this information for where it is really impacting women for them to reach their potential, being optimized with hormones. And that's where we are now, which really isn't widespread. It's still very new. And I feel like these conversations, my opportunity on my platform and using my voice is to help women understand as well as providers that we have so much more to do, but we have to allow women to understand how to best potentialize their lives and longevity.

A (10:37)

Right. It's almost as though women, when they're going through perimenopause, you just have to tough your way through it.

B (10:44)

Oh, God, yeah.

A (10:45)

And then menopause is just a part of life. And that's the way. You know, my mom, she was brought up with that type of mentality. And it's. It's like the decline is inevitable kind of mentality. And it's really sad because, I mean, you're a perfect living example of it. You don't have to decline, right? No. You can stay your most powerful active self while maintaining your biological health, your bones, your cardiovascular health, your brain, all of it. And there's tools available now. It's just a mindset shift.

B (11:13)

It really is a big mindset shift. And I think that's gonna take some time because of one what was told for so long. But also, women live longer than men typically, but more years and poorer health. And I think that when we are able to connect the dots for women, for them to, you know, take a step back and sit in it and say, if I want to live longer, and I potentially will live longer than my spouse, my partner, or just men in general, why would I want to do it in poorer health and how do I take charge of that? And I really do believe midlife is that opportunity to switch the narrative to kind of work on the glitches like we were talking about. I say the analogy is best used as in a tugboat you can change direction really quickly.

A (11:56)

Right.

B (11:56)

But that's not what longevity is because it's very hard to change something very quickly, rapidly. Do big overhauls is a cruise ship. Right. A cruise ship can change very slowly, but it can change in a few degrees. And all of a sudden it's sailing in a whole different direction. And so I really want people to take midlife as this opportunity to project what is my 60s, 70s and 80s going to look like? Or even 90s. Now is the time to reset that.

A (12:23)

Yeah. And you know, I feel like there's this time of perimenopause that's very nebulous. Right. Even, you know, talking to women that are in perimenopause, it's hard for them to really understand that this is due to hormonal changes and there's a lot of gaslighting going on during that time as well. So when should women really start thinking about perimenopause? Like, what's the age? What are the symptoms? When they can start recognizing like, oh, this is happening to me right now, this is a hormonal shift that's occurring and get out of this mode of like, you know, I'm dealing with brain fog, Maybe I'm just not, you know, maybe I'm too stressed. That kind of mentality, you know.

B (13:01)

Yeah. I think when we think of perimenopause, it is very nebulous. There's no like magic age at which it starts and everyone will experience it differently, whether that's with ethnicity, whether that's with what your family history is, or just you as an individual. When your hormones start to shift because the shift really is between estrogen and progesterone and where they start to not have as much as a fraction, fine tuned kind of relationship, which is what you typically see during the reproductive years. So as it starts to shift, it could be because of nutrition, it could be because of obesity, which your estrogen and progesterone ratio start to shift. So that kind of magic age at which it starts can be different for everyone. So the real goal, which is what I teach my patients is self awareness, right. Embodiment where you're like, something's starting to happen and not kind of pushing it out of your mind, like, and a lot of women Are, you know, very good at doing this Is like, something's happening, but I have other stuff to do. I'm not gonna pay attention to it. And so as those subtle signs and those signals start to come, whether it's brain fog, fatigue, whether it's, you know, what, I am having a hot flash or my sleep is really being interrupted, or my libido is paying attention to it, because it doesn't necessarily mean that as soon as it starts, you have to be on hormones. It means, when is this starting to impact my quality of life, my daily life, my who I am as a person? And I think that that's really when you start to have the conversation of one. What is it? What are hormones? What is happening and is it for me, you know, I always want women to understand hormone therapy should not be what we've seen typically in women's health, like breastfeeding and bottle feeding or C section and vaginal. Like, you're shamed if you don't do one or the other. If you walk out understanding hormone therapy and you still decide not to, that's okay. But I still want you to understand the benefits and the risks that come with it so you can make the best decision for yourself. I'll give you a little bit of my personal story. So here I am, obgyn, right? Like, I should be a hormone expert. I specialize in perimenopause and menopause. Darshan. About three years ago, I was like, why am I not multitasking? Am I forgetting I can't, like, come up with words? Went on for months. Me.

A (15:15)

Yeah.

B (15:16)

And then finally I was like, well, I'll be damned. I think this is perimenopause. And so because I was like, I've always been a fan of hormones. I was like, I'm going on hormone therapy. And I did. But imagine for someone who's in the field, like, really, like, pays attention to it is taking months and months to being like, what is going on with me?

A (15:35)

Right?

B (15:36)

So I can't imagine, you know, a woman who maybe doesn't even know any of these things to being like, it could be years. And that's where I see women coming in five years, where they're like, I've been living like this for. I'm like, let's stop this.

A (15:46)

Yeah, it's so true. And, you know, I think also there are subtle changes, like you mentioned, like, you could not come up with words or whatever. And then there's also, like, changes that occur maybe in relationships with your friends and family. Emotional changes, resilience to stressful conversations. Right.

B (16:06)

A lot of stressful conversations. I see that a lot in relationships. I did a TED talk this year in October, and obviously talking about menopause. But what I really wanted to look at was the scope and lens of emotional resilience because there is an interplay between neurotransmitters and that flux in estrogen and progesterone. And so what we do know, it's very much evidence based, we see it in the literature, it's been studied, that as estrogen starts to decline, the interplay, which makes sense, and you would see it between a hormone and a hormone, are going to change and shift. So dopamine and your norepinephrine and your serotonin and your GABA also start to shift because they respond to estrogen. And so the amygdala, as far as our mood, our center for mood and the ability to hold emotional capacity is changing with the estrogen decline. So women do struggle with this. They come into the office, they tell me about it all the time. But we're not creating this kind of connection between the dots of estrogen decline, neurotransmitters, tolerance, emotional capacity, stability in the relationships. In social media, you're starting to hear more of women just leaving relationships, not being able to. Their tolerance for what happens in relationships have changed. And I don't necessarily think that's the answer for everyone. I think that there can be instances where that may be what women need to do. But I do think that women, in stepping into this emotional capacity and what they don't have tolerance for, this is where we need men to show up as well.

A (17:44)

Yeah, that's true.

B (17:45)

You know, taking responsibility and changing roles. I think everyone plays a role in midlife for both men and women. We have to really change what the role is for each of us.

A (17:55)

Yeah, it's so powerful to talk about that because, you know, when you look at what happened between men and women during this time period, and we know, sadly, there's more divorces in this time period than.

B (18:07)

Yeah.

A (18:07)

And the divorce rate in the United States is just climbing and climbing and climbing. And a lot of it has to do with a lack of emotional connection, a lack of passion, a lack of just even caring. Right. And some of, some of that, or maybe all of it is due to hormonal changes that we feel like we've changed, but it's really our hormones that have changed.

B (18:28)

Right. And it's a part of our experience as humans. And I think if we look at it instead of, you know, playing the blame game and maybe being a little bit defensive is, how do I show up in this role? How can this role be changed or attuned to? And hormones do have a part in that. And I have seen a lot of women who have come back, literally and said, my relationship, it's not like it makes it perfect. That's not what I'm saying is that they're like, I am now able to not be as annoyed or irritated or less tolerance for the things that I did see because I'm now on hormones. So that is a beautiful story to me that hormone replacement therapy can impact emotional capacity.

A (19:09)

I mean, you probably heard this so many times, like, you saved my marriage. I hear that from the husband and the wife. Once a woman goes on hormone replacement therapy, it can be incredibly powerful for relationships. Absolutely. So when does a woman start thinking about perimenopause at like, what age?

B (19:26)

I would say the conversation has changed. I would say even in the last five years. I think the perimenopausal conversation can start even in the late 30s.

A (19:33)

I agree.

B (19:34)

Before I used to start having these conversations to mid to later 40s and now again shifting back to later 30s. I think another reason for that too is as women are starting to push off childbearing years, having kids a little bit later, we do start to see in the postpartum phase, as they're starting to kind of get back to their pre pregnancy hormone rates, then they're like kind of shifting right into the perimenopausal phase. And so you see this extension of postpartum into perimenopause, which sounds a little bit depressing, but it's not, I'm telling you, is that we're able to now kind of reclaim that by having women say, okay, let's talk about these hormones and how you might make this entrance into perimenopause a little less kind of catastrophic.

A (20:21)

Yeah, yeah. And it happens a lot now because, like, to your point, women are pushing off having children and they're coming right up against menopause now in having children. And so many women are actually getting pregnant during perimenopause.

B (20:33)

Exactly right.

A (20:34)

And they drop right into menopausal symptoms.

B (20:36)

They go right into it. And it is a little bit confusing even as a provider, because we do want to give women still that timeframe for postpartum kind of resolution. There is a huge flux between estrogen and the type of estrogen that kind of is predominant in pregnancy to going back to more of what we would say pre pregnancy estrogen levels. So we want at least to give them that time and space to get back there. And then once that happens, is is this really perimenopause or was it just because you were later into your childbearing years that maybe that kind of getting back to pre pregnancy was a little bit longer?

A (21:14)

Is there a relationship between like postpartum depression and when women are getting pregnant.

B (21:19)

As far as do they increase their risk of having postpartum depression? Postpartum depression one is underdiagnosed, often dismissed. What we do see is people who have a higher risk of having postpartum depression have had some type of mood disorder in the past or if they've had previous pregnancies and experienced postpartum depression, they are definitely at increased risk of having postpartum depression again.

A (21:43)

Got it, Got it. So if you're say a 30 something year old woman, 38, let's just throw out a number and you're experiencing symptoms. Maybe you're forgetful, maybe you're less resilient emotionally or maybe you are getting brain fog. What's the next step a woman should take?

B (22:01)

There next step is always that conversation. Because as physicians, you know, I think it's always important not to, as we get into this kind of, I'll call it a craze for now of perimenopause and menopause is to then dismiss, dismiss other things that it could be. Now thyroid disorder is very common, especially at the age of 40 and beyond. That's why we screen for it at that age. So it's one of the most endocrine disruptions that we can see in women after the age of 40. So making sure it's not that I care so much about mental health that I have two therapists in my practice.

A (22:31)

Oh wow.

B (22:31)

Because I do think that women, we are busy taking care of everyone else, not ourselves. That I do want to make sure that there is some calm and resolution in the mental capacity as well, whether you're perimenopausal truly or not. So I do think that's something to consider. And then also stressors is teasing it out and saying what is really going on in your life and how do we kind of present that? I think that those are important things to at least kind of put to the side. So true nutrition, I think nutrition does play. We know that the gut health is so important and that blood brain barrier can really, really get either good supply or bad supply depending on what we're eating. So I have a Functional nutritionist in my practice as well. Because that shift is important and that does help. We've seen studies that depression can actually be cured by changing diet because of that blood, brain barrier and gut health. So I always want to make sure those things are ruled out. And then I have the conversation about, here's what hormones can provide. Do you want to try? Because trying to me is everything. If it doesn't work out for you, you don't love it, you think it's crazy and you don't, you want to get off, guess what you get to do? Get off. That's like perfect. Patient autonomy is allowing people to take part in their health care.

A (23:53)

Yeah. And like to your point earlier, it's not a yes or no decision. It's, let me think about it. It might not be right for you now, but there might come a point where you're like, I need to try something different. And that's when you do it. And so yeah, I always leave it very open ended for people like you, like you do yourself. You tell them the risk, the benefits and at some point they're going to be ready, you know.

B (24:14)

Yeah.

A (24:14)

At least they have the information back.

B (24:16)

Three months later, a year later. But they left at least with some good understanding of what's available to them. And it shouldn't be done in a shameful way where you're like, well, if you leave today and you don't start, you know, like, you know, I don't know, you're going to die or something. I'm like, don't make it dreadful. Let them have that, that intake and input into their own lives.

A (24:38)

Exactly. I really believe in that is making it a choice and not making it a. You must do this. At this moment. There's very few things in medicine that are like that, you know.

B (24:47)

Yeah. I tell them, I said, unless you're making a decision where I'm like, okay, that you'll die from that you can make your own choice. You can creep into it, crawl into it, run into hormones if you want, dive into it, whatever you want to do.

A (25:00)

And I love the idea of adding emotional support and therapy to the whole paradigm as well, because that can really take care of a lot of the symptoms just by doing that.

B (25:12)

Oh yeah. I think that mindfulness when it comes to breath work, meditation has really even helped me. I mean, I think a lot of this too as going through perimenopause is my personal story as well, which I'm. That's why I'm so equally important to share my side of it as well. So that it's not this transaction of, I'm the doctor, you're the patient. This is what you should do, is, hey, I'm going through it too. Who does not love a therapist? I think that everyone should have a therapist. And I think that my therapist has also helped me understand the embodiment of mind body medicine and what plays into the experiences that I have, you know, from a physical symptom. Can a lot of times be from how I think, how I embody and how I process it?

A (25:54)

Absolutely. You know, as physicians and also as humans, we can have a lot of empathy for what people are going through. Right. And so for my male patients, obviously, you know, I'm. I'm 53 now. I'm going through testosterone replacement therapy. I understand what the lack of testosterone did for me. And I think just realizing too, like, every. Every human is different. Every man is different. So some might need it, some might not. But the ones that do need it, I have a lot of empathy for because, you know, there's a lot of negative talk around being a testosterone replacement therapy in the traditional medical community. I feel the same is true for women as well.

B (26:29)

Yeah, there's been a lot of obviously negative talk when we think whi. But also I think, just like whether it's through storytelling, cultural society, is that if you have to take something, I think some people look at hormone replacement therapy as medication.

A (26:45)

Yes.

B (26:45)

And I'm like, let's stop that narrative as well. This is something that your body actually produced from birth.

A (26:50)

Right.

B (26:50)

And so when we look at 1900s, life expectancy of women was like 58. So now that we've expanded life expectancy, we haven't accounted for that void of 20 years of lack of hormones.

A (27:02)

Exactly.

B (27:02)

So what do you think your body's going to do? It's like, peace out, man. I'm not really doing anything here. I'm just a shell.

A (27:08)

Yes. And this is so true. Right? You're just a shell. Your thymus gland, for example, starts degenerating in adolescence. Your ovaries and your testosterone, if you're a man, starts degenerating, like in the late 30s, and you just lose it. Your body's tired. Your body just can't make the natural products.

B (27:27)

It's not even getting the fuel. So here we are revved up. If I think of our bodies as these beautiful machines, they're revved up in 20s and 30s with all the accoutrements that it needs, and then it starts to decrease. And we expect our Bodies to function at its best. Optimization is probably the most used word that we use in our practice as well. Because we're not medicating you, we're not having you in a disease state and treating you. We are optimizing the beauty of your body and this machine.

A (27:58)

Yeah. And that's the mindset shift that people need to have, is that we're giving your body back what it had before, and we're living longer. So during this aging process, our bodies were never meant to live this long. That's why the hormones decline. Right.

B (28:11)

And estrogen, is that part of it, that the fuel? When I think of, like, fuel of, like, getting this body where it needs to be, I think we have typecast estrogen and progesterone and even testosterone as kind of sex. We call them sex organs.

A (28:23)

Right.

B (28:23)

So what do you think of when you think sex organs? You think of your reproductive system. It's just in the pelvis. I'm like, your muscles, your brain, your bone, your heart have receptors for estrogen.

A (28:32)

Right.

B (28:33)

So if it's not getting the message, if it's not getting the fuel, it really is like, I can't function at the optimal level that you want me to without the fuel. And so that's why we start to see. And you know, this. You talk about it all the time. The increase, you know, when you've presented kind of how our body responds. Hypertension, heart disease, our bones become fragile. Our brain has a change in it as well. Insulin and glucose, they're like, I'm out of here. Metabolic health takes a dive. A lot of that depends as well on estrogen.

A (29:01)

Yeah. And it's so such an important fact to realize, just to reiterate, estrogen is not just about sex and reproduction.

B (29:09)

Right.

A (29:09)

It's really about muscular health, bone health, metabolic health health, and brain health. Right.

B (29:14)

All of them together.

A (29:15)

And cardiovascular health.

B (29:16)

Yes.

A (29:17)

There's so many different reasons. We need to make sure that estrogen, and both for men and women, I think, is an important hormone. Right. Let's dive a little bit more into another area that you speak a lot about, which is muscle fitness and bone health. Right. So can you talk a little bit about how women should think about training once they're going through perimenopause and then menopause.

B (29:38)

Yeah. We talked a little bit. When you think of, like, pregnancy, say, Right. Women have a biological reproductive window. And during that time, a lot of what we've seen and really what does help fuel this machine is cardiovascular exercise. And when we get into this perimenopausal phase for hormone decline, we start to see the muscle also take an impact, and that impact is not great. That impact is we start to lose our lean muscle mass and decrease in our strength as well as our bones. So if we were to put bones and muscle into kind of the same complex, right. They're the. They work together. Right. Is that we see this shift and decline in muscle mass as well as bone. So that happens as much as early as in the mid-30s. So now you have it compounded with the decline in estrogen. But we have never told women to switch how they work their body and how important exercise is. When we think of resistance training, specifically weight training. So heavy muscle, you want your muscles to have that impact and you want them to build in order to keep you strong for a longer amount of time. So that's why we hear, and if you haven't heard, whoever's listening, that muscle is the organ of longevity because it sustains us not only from a strength and power perspective, as well as your metabolic health.

A (30:56)

Exactly.

B (30:57)

Your metabolic health is so important. And when we think of glucose and insulin, when glucose enters as fuel, whether you get it from food or whatever, and also the quality of food, muscle is one of the biggest absorbers of glucose.

A (31:09)

Exactly.

B (31:09)

So if you're not building your muscle, it's not absorbing glucose, but it's also not keeping you strong throughout these years in your 50s, 60s, and 70s. And so resistance training is key. I did work out before I came.

A (31:20)

This morning, and you're amazing.

B (31:21)

Is that we used to live in the age of Jane Fonda, who I love very dearly, and Richard Simmons cardiovascular. And cardiovascular exercise is not bad. But it was exercise for weights was for the bros, right?

A (31:33)

Yes, exactly.

B (31:34)

You guys go to the gym and you grunt and lift heavy weights. And women were not allowed in those spaces. All the while, their muscles were depleting. Their bones were getting, like, really, really weak. So we're like, no wonder there's osteoporosis.

A (31:46)

Exactly.

B (31:47)

No wonder there's muscular waste as we age. And so I think it is one of the key things that I think is very important. But not easy. It's easy said, but not easy done to incorporate weight training into your exercise routine. And so Even if it's 20 minutes for three times a week, you know, it doesn't have to be laborious, it doesn't have to be an hour. But your muscles depend on. On weight training and resistance training. And that, to me, is your longevity wrapped up in exercise.

A (32:17)

Absolutely. Your metabolism Lives in your muscle. You have these hormones called myokines that are secreted from your muscle that affect every other organ in your body. It's such a critical piece of the puzzle that is ignored in this kind of calories in, calories out mentality that we've kind of been raised in, where it's like, oh, I ate an extra donut today, so I'm gonna just run an extra hour on the treadmill. And in reality, that doesn't work anymore, especially as you enter your mid to late 30s. And we really gotta have this shift from cardiovascular to muscle training. And to your point, also, like, your muscles and your bones are connected, obviously, osteoporosis is a huge piece of the conversation for women, especially as they age. And one of the things that I've been looking a lot at is not just checking the amount of bone you have, but the quality of the bone. Right. And so can you talk a little bit about that? Are you doing some of these things?

B (33:11)

Yeah, I do. So I do. So the DEXA scan, which is a scan of the bone, which in traditional medicine, what is the age that we do DEXA scans in women?

A (33:19)

Yeah. Like 70 or 65.

B (33:21)

65.

A (33:22)

Right.

B (33:22)

Their bones are like, powdered at that point.

A (33:24)

Exactly.

B (33:25)

They're like, I really don't even have any, like, trabecular or cortical strength. So I'm just here. And if you fall, I'm out.

A (33:32)

Yes.

B (33:33)

So what we do is we should be doing these DEXA scans much earlier to tell if a woman is osteopenic or osteoporotic, which means that they are, like, way below the deficiency of what their bone needs in a bone mineral density strength. But it also looks at muscle strength and the capacity for how much fat is in the body as well, visceral fat. So when we think of bone and scanning, I, one, want women to get that earlier. Two, I'm like, if even if you have osteopenia, which is, you know, a lower density for bone mineral density is. Here's where we get to impact that. We can do that through nutrition supplementation, resistance training, and weight, as well as hormone replacement therapy, which actually, when we think of hormone therapy, FDA approved for bone mineral density and osteoporosis. So I feel women do not know that.

A (34:24)

No.

B (34:24)

And they don't know that there's estrogen receptors on their bone. But what a beautiful way that you have so many different modalities to improve your bone strength through nutrition, exercise supplementation, hormone therapy. So why not take part of all of these different tools that are being allowed for you and doing it bite size. And it's not this overwhelming thing of you have to do one thing and, like, go hard and you have to, like, change your whole algorithm by, you know, in one month. That doesn't work for anyone, which is why fad diets don't work, which is why when people think that they're gonna do one thing really hard, that it's. It never works that way. This is really a lifestyle change, and this is something that I want people to incorporate very slowly over time so it can get consistency, which is sustainability.

A (35:09)

Yeah, it's so true. And I really like that, you know, doing smaller changes. But multimodality is so much more sustainable over time. Right, Exactly. You know, one of the things that our friend Vonda Wright talks a lot about is jumping and giving your. Giving your bones some additional pressure through either jump rope or stomping upstairs. And, you know, just really using your muscles and your bones at their capacity in everyday life.

B (35:37)

So, like, if you think of, you know, jumping and it doesn't have to be okay, now I have to schedule 30 minutes to jump the rope. It could be when I get home, I'm gonna jump up the stairs on each step, or even if I'm at work, I'm gonna take some time to maybe do some squats. So I think putting it into your lifestyle in small, little increments is the best way to do it, because studies have shown that's where you get the best impact. And return on investment is doing small changes over a small amount of time. We would say the same thing for finances. Right? No financial advisor would tell you, okay, when you retire, that's when we're going to start saving. They're like, no, we want small little deposits over time. And then you're going to get this huge return on investment in time. Same thing for our health.

A (36:21)

It's so true. Yeah. You know, it's so funny because I'll ask patients a lot of times when they come and see me, when was the last time you jumped? When was the last time you broke out into a sprint? You know, and most people can't remember. They can't remember when they jumped the last time. Right. We just stopped jumping.

B (36:36)

Yeah. There was this thing on Instagram, or it was this trend where they would tell adults to skip. Like, literally just skip. You know, when you're a little kid, they skip all the time. They couldn't do it. They didn't know how because they were like, it was the Funniest thing because we're like, it's just skipping. But they didn't know how to do it because we just stopped doing it. So it's like, what is the play that we forget as kids?

A (36:57)

Yeah.

B (36:58)

Is the same way that you can incorporate jumping or skipping.

A (37:01)

Yeah. Even squatting. Like, I know I can't even squat.

B (37:04)

They cannot.

A (37:05)

Right. It's. It's just.

B (37:06)

And that actually is another thing that we talk about with muscular and bone strength is the lower part of our body is actually what's going to when we look at longevity. So that is an important part as well. Is watts and just being able to get down to the ground. Functionality. Right. Can you get down and pick up a piece of paper? Can you get on all fours? Can you travel and put your luggage in the overhead bin?

A (37:29)

Yes.

B (37:30)

These are things that you should strive for. And how you should look at it is not this template of I have to do these things because these two doctors said on this podcast that that's longevity. No, I want functionality as well.

A (37:40)

Exactly. Yeah. One of the tests that we do for all of our patients here is we do a sit to hand test. And so.

B (37:45)

Oh, I love that.

A (37:46)

Yes. So. And it's incredibly surprising once again, how many people cannot stand up from a sitting position without using their hands to push them up.

B (37:54)

I feel you're gonna have to test me after this session.

A (37:57)

Okay.

B (37:57)

But we're not gonna come back and tell the results.

A (37:59)

Yeah, we won't tell them. I'm sure you're gonna be fine.

B (38:02)

But if not, we're not coming back and telling.

A (38:04)

But you know, it incorporates lower body strength, it incorporates balance. You know, there's so many pieces of the puzzle that this incorporates. And intuitively, if you ask someone, can you do this? A lot of people say yes, because you don't feel like you lose that until you're like 65, 70. The reality is there's 35 and 40 year old patients of mine that can't do it. Yes.

B (38:26)

So interesting.

A (38:26)

It's really interesting and it's sad, obviously, but I think number one is first knowing you have a problem and then working on it. Little tests like that can really accelerate someone's health journey because they understand that they are way behind the norm. You know, we have a grip dynamometer in our office today.

B (38:45)

Yes. I love the grip test as well. I think that that's a beautiful test of longevity, muscular strength. Farmer's carry.

A (38:52)

Yes.

B (38:53)

Have you done it? The One that's for so for women. It is. Is it 2/3 of your weight that you're supposed to carry.

A (38:59)

We aim for 1.1x your weight for women and 1.5x your weight for men.

B (39:04)

Great.

A (39:04)

Carrying it for one minute, you know, both hands. We like to use, like, a trap bar, but if you can, you can just get two dumbbells. And it's really hard.

B (39:13)

It is hard.

A (39:14)

It's really hard. Right.

B (39:15)

But all of these tests that we've said, the grip test, sit to stand, and the farmer's carry and even the hang test as well, these are things that actually can be improved over time. So I think when people, you know, maybe, and you can give this experience because you. You actually do it here in your clinic is sit to stand. Do you find that people become maybe unmotivated or maybe feel that, oh, no, I'm here, I can't get better?

A (39:41)

I think what I've seen is more the opposite. I think once they have the realization, they understand the urgency of things.

B (39:47)

Good.

A (39:47)

And then they start getting into a routine and a plan to fix it. You know, I think that, you know, motivation is tough. Right. Like, we struggle with motivating our patients all the time. One of the key kind of tools I have for motivation is actually hormone replacement therapy.

B (40:05)

Yes.

A (40:05)

It gives people that quick win. They need to really start accelerating the rest of their journey.

B (40:11)

And that means that it's internal and going towards external. So a lot of that internal joy of I feel better. Right. So that is, again, going back to emotions of, like, the feeling of who you are and what you can do will then inspire you to externally feature that with showcasing. I'm gonna start going to the gym. Or we even see that with GLP use of I feel better. I feel that my weight has gone down, and now I'm going to actually do more of the work that started this momentum.

A (40:43)

That's exactly right. And so, you know, a lot of people look at GLP1 sometimes as a kind of like the easy way out. But in reality, what I've found more than that is the people that are doing GLP1s are the ones that struggled with everything else, and you give them that little bit of help to control kind of the food noise for just a few months, and it completely changes the destiny of their health. So I'm a big believer. And, you know, this has been very helpful in perimenopause GLP ones. Right.

B (41:12)

Oh, my gosh. There was a study that was done, which I'm so glad I figured it. This was why this was happening before the study came out was that women who are on a GLP will actually see more success when they're simultaneously taking HRT versus women who are not. And one of the reasons why that makes sense and is true is because you have estrogen, which is contributing to also glucose and insulin and how they're functioning and also feeling better. Right. And so that brings into the scope of how everything that transpires in our life is not just one thing. It is never just one thing. And that's why I think, you know, coming out of traditional medicine is that was the approach, the nail hammer approach. You have this, I'm gonna fix it with this one thing. But really it required so many different features that was not being discussed and talked about. So I definitely see in my practice, we use GLP1s in addition to hormone therapy. Not everyone does it simultaneously, but we do see a better outcome when they're taking both.

A (42:12)

I'm so curious about this study. That's awesome information that someone actually studied this because this has been kind of like my clinical gestalt is like, I'm gonna put you on hormone replacement therapy. Here's a GLP1. At the same time, even if it's a micro dose, it's really been synergistic for my patients.

B (42:27)

Absolutely.

A (42:28)

And you know, they get that little bit of weight loss that maybe they've gained a few pounds during menopause and has been helpful in that way as well. But they do work really well together.

B (42:38)

They do.

A (42:39)

And I think people should also know that, you know, GLP1s, they're. They're not like a traditional pharmaceutical, they're like hormones. Our bodies biologically make these.

B (42:47)

Yeah, it's a peptide that's naturally made in the body, just like estrogen and testosterone and progesterone. So we're really giving the body the ability to utilize this naturally made peptide and hormone to actually fuel our body. And so that's how it should be explained again, is not as a drug, but we're giving your body something back that it already had. So I find that when people really take a step back and look at it as, I'm not taking something that is treating a disease. I'm taking something that's going to ultimately help my body in the way that it wants to do something, then it's a win.

A (43:22)

Exactly. So do you think there's a world in the future where everyone will be on hormone replacement therapy? Every man and woman?

B (43:29)

I, you know, I really hope so, and here's why. I'll preface it with it doesn't necessarily mean if you're not taking it, that you're a bad person?

A (43:36)

No.

B (43:37)

What I do know, and you have seen this in the studies, there's so much data on what our body needs in order to function. And so if it doesn't have that ability to function without the fuel or the source or the hormone that it's been given, it really can't do its job. And so I think when we look at aging, when we look biologically at what our cells start to decline, it really then increases the ability for it to have disease, for it to have cancer, for it to have frailty, for it to have decline in cognition. And you know, dementia is. We have the ability in our lives. And I think we're really at this kind of. I think it's really historic. When we'll look back in maybe 30, 50 years, is that in midlife. And I'll really focus on midlife because I think we have studies that show the decline after a certain age is almost categorically. It's like you're really gonna have to do a big overhaul. So we have this opportunity in midlife to give ourselves the best chance ever in not living longer, but living healthier as we start to age. So I really hope that we would see a future like that. I'm excited to see what other modalities and how we're gonna distribute that. The blends of what we see in estrogen and progesterone and testosterone. I think that I have seen in my own practice presenting to women the different ways that they can do it. Whether it's sublingual injected, whether it's a cream, a palette, so many beautiful ways to do it. And I think it's brushstrokes. I think this is artistry. I think everyone responds differently. And I want people to take it on as something that is adding to the beautiful picture and kind of context of what they want their life to. To show up as.

A (45:23)

Absolutely. And I really respect the way you do it in your practice. It's the same way we do it. It's not just a one stop shop just for hormones. There's so much nuance to it, there's so much precision. To your point, doing it right really requires precision. It requires having multiple modalities at your fingertips. I love how you incorporate. In fact, even nutrition, functional nutrition, mental health, putting it all in one place as a. The overall picture is a much better way of doing it and much more successful for sure.

B (45:54)

When I was in traditional medicine, I would send a lot of My patients, I'd be like, yoga is going to be great for flexibility, I would say, or posture, or making you feel better about yourself. I realized at that point this was maybe one of the biggest. Not the biggest reasons, but kind of one of those moments where you're like, I got to leave. She inboxed me in the portal. The portal, which we all hate because 5 million questions come in there. And she took what I said, but then she goes, but where do I go? And I was like, how do I provide that for everybody if I don't even know where to sit? Then I was like, well, where do you live? Then I started looking up. Can you imagine, like, stopping your clinical, like, day of yoga scene? I was like. Because I really wanted her to go. Because this can't be the answer. The answer needs to be this is all provided for you in one space where you feel safe, where you don't have to ask, where do I go? And we will contribute to this momentum of what you're trying to accomplish in one space and exactly what you're doing. It's the same thing.

A (46:48)

Yeah. I think longevity. Doctors are putting these things together for people in a very responsible way. And it's going to be a whole new type of medical system that we have, one that's there for disease, you know, disease treatment, like emergency situations, and then where everyone else should go before they get there, which is a clinic like yours or mine.

B (47:07)

The hope is that obviously we want more people in the well space, but obviously not everyone can be there, and it will take time. But that's what I feel that we were trained for, is when people are in a state of disease or catastrophe, we know how to help them. But my hope is that as physicians and healthcare providers, we are expanding the ability for people to stay in the well space.

A (47:30)

Yes, I totally believe that, and I'm so glad to be on that mission with you. Me as well. Well, this has been a fantastic conversation, and I look forward to having many more.

B (47:40)

Yes.

A (47:41)

Could you tell the audience where they can find you and hear more from you and about your clinic?

B (47:46)

Absolutely. So last year I came out with a book called Generation M. It really has a lot to do with what we were talking about today, how to incorporate midlife into longevity and the multiple ways to do that. So you can get that on Amazon, Barnes and Noble, and then find me on Instagram. I think that's probably my best kind of platform, which is Jessica Shepherd. MD S H E P H E R D M D and then also Modern Menno which is kind of more of focused on midlife and longevity is modern Menno on Instagram as well.

A (48:17)

All right, thank you so much for joining me today. This has been a true pleasure.

B (48:20)

Yes. Love having time with you, Darshan.

A (48:22)

Thank you. That was a fantastic conversation with Dr. Shepherd. I hope you guys all enjoyed it. Here are my top five takeaways from this episode. Number one Perimenopause often starts earlier than women expect, sometimes in your late 30s. There's no magic. Age and movement, stress, nutrition and emotional health all influence these hormonal shifts. Number two, Most menopause guidance is based on outdated, misleading research. A 20 year old cardiology study created unnecessary fear around hormone therapy. This was the Women's Health Initiative, leading many women to tough it out instead of getting real support. Number three, Emotional symptoms are just as real as physical ones. Declining estrogen affects, neurotransmitters and emotional tolerance as well as physical symptoms, brain fog, stress intolerance, emotional strain, and even rising midlife divorce rates all may be attributed to perimenopause. Number four Muscle is the organ of longevity, especially for women. Resistance training is essential in a woman's workout routine. Cardio alone cannot maintain metabolic health, bone density or functional strength. The body needs to jump and use muscles to fully extend and keep them healthy. Number five Small, consistent lifestyle changes build the strongest foundation for aging well early awareness, proper testing, including earlier DEXA scans, emotional support, nutrition and when appropriate, hormone therapy can transform the perimenopause experience. Thank you very much for listening to another episode of xtend. If you like this, please share it with a friend who's in need of this incredibly vital information. Thank you and see you next time. Thank you so much for listening to the podcast today. Please remember to subscribe if you like this episode and give us a good review and share a link with your friends. It really helps to support all of our efforts. I also want to remind you that the information shared on this podcast is for educational purposes only and is not intended to replace professional medical advice, diagnosis or treatment. Please consult with your healthcare provider or physician before making any decisions or taking any action based on what you hear today, especially if you have any underlying health conditions or on any medications. Your doctor knows your personal health situation the best and it's always important to seek their guidance.