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Dave Asprey (3:26)

I'm kind of a fan of hormones. And the reason for that goes deep. It's because When I was 26, my doctor called and said, dave, you have less testosterone than your mom. And that was actually true. And getting my hormones in order has made a huge difference. And when I wrote my major book on fertility, which, believe it or not, was my very first book, I went really deep on women's hormones and men's hormones and how they affect our brains, our consciousness, and how they affect longevity. Been a huge supporter of hormone replacement therapy even back when the FDA said it was unsafe. I'm like, that's because they're not doing science. And I was so honored to be able to interview the new head of the FDA on stage the week that he announced that they were wrong. For 23 years and that hormone replacement is now standard of care for women, which I think is only reasonable. So our guest today has made a lot of strides around hormones and women's health. And one of the effects of hormones is, well, it kind of makes you like your life better for lots of reasons. And we're going to go into that as well. So stay tuned for a Masterclass on Hormones. Dr. Sarah, welcome.

Dr. Sarah (4:49)

Thank you for having me.

Dave Asprey (4:51)

Now, why should men get way more hormone therapy than women? I mean, there's lots of reasons, but you must know them.

Dr. Sarah (4:59)

I love the sarcasm. Cause they shouldn't.

Dave Asprey (5:02)

I just want to see the look on your face.

Dr. Sarah (5:04)

I love it.

Dave Asprey (5:04)

Yes, I am being sarcastic, but it feels like, I mean, if you're just a doctor and you're sitting there and you're going, I could just give a guy some testosterone, maybe thyroid, and it's pretty much good to go. And women, it seems like you guys are all different and like all over the place all the time. What's up with that?

Dr. Sarah (5:23)

Imagine if I were your doctor and I said that, no, you can't have testosterone until you stop making sperm for an entire year. And then we'll give you a tiny amount in a patch on your skin, which we know doesn't work, and we'll keep your levels about 100 picograms per milliliter. That's it. Because testosterone's dangerous and it might give you testicular cancer.

Dave Asprey (5:44)

Oh, like Peter Attia. Oh, I know what you're saying.

Dr. Sarah (5:48)

So imagine that that was the care that we gave you. But this is happening to women every day.

Dave Asprey (5:55)

So there's two words that solve this problem entirely. You know what they are? You're fired. And if your doctor says that to you, those are the appropriate words, Right? And for men, if your doctor did that, you're fired. Your doctor won't give you testosterone, your labs or your symptoms don't match it, you're fired. And if you're a woman and your doctor says, eh, get a better doctor, your doctor works for you. That's how it works, right?

Dr. Sarah (6:15)

It does. Except for with women. The problem is you go to another doctor. Not only is it not standardized, but there's no formulation that works. So we still use patches and pills and creams that one don't absorb into the body. Only 30% of patches or topical creams absorb pills are degraded completely in the liver. So only 80% of them, you know, 80% actually gets metabolized into toxic metabolites. We don't give men testosterone pills or topical creams or patches.

Dave Asprey (6:47)

I take testosterone pills. Hold on.

Dr. Sarah (6:48)

But they're lymphatic, so they go right into the lymphatic system. We don't have a progesterone lymphatic for women, for example. We do not have equivalent formulations. So even if you were to go find a better doctor that was going to give you your 45, say, having symptoms so you're younger than menopause and they're willing to put you on something, there's nothing available that would work for you. So as a 35 year old, when I was going through it, I tried everything.

Dave Asprey (7:12)

Literally everything is for progesterone specifically, all

Dr. Sarah (7:15)

of them, because women need all three hormones. So really nobody has designed or innovated on women's hormone therapy since the 1960s. And those were made by men. And nobody's really looked at women's hormones in a comprehensive way. How do we have this one at a time approach? Okay, we'll just give you a little bit of progesterone, a little bit of estrogen, and it's very fear based and it's not based on any science.

Dave Asprey (7:41)

Well, when, when I look at women's labs with unlimited life, which is my concierge longevity program, I do find that some women need more progesterone than others and some women need more estrogen than others. Like isn't there a case for being able to have these things in different ratios?

Dr. Sarah (7:58)

So I think that you could optimize a little bit, but the problem is you're still micro like majoring in the minors. You're still going to raise her patch like 0.5.

Dave Asprey (8:07)

Hey, we don't like patches.

Dr. Sarah (8:08)

Yeah, so what, you know, how do you get it into the body? So progesterone is this massive molecule and the problem is, it is an engineering problem. How do you get it into the body better? Yeah, so yes, some women might need different ratios, but overall they need levels that are physiologically appropriate.

Dave Asprey (8:22)

Yes.

Dr. Sarah (8:22)

Getting the levels up, start there, which suppress the fsh and then you can, can you tweak it? Yes, is somebody. But you can also manipulate diet. You can lower fiber. Women are like overdoing fiber, eating more than 30 grams a day. And fiber will lower your estrogen levels. So can you, you can switch to diets, you know, from a plant based to an animal based, for example, you will raise your estrogen levels that way. So you can optimize. So what you lay the foundation. You get the hormones up to where they need to be and then you can further optimize from there.

Dave Asprey (8:56)

I love this. You're just like shitting on fiber. Thank you. The thing that drives me nuts is women need more nourishment than men on average. Your systems really like to have adequate nutrients, adequate protein, and you'll become stressed more quickly than men will when there's lack of nutrients. So if you're taking handfuls of sawdust every day, which is what bulk fiber is, and it absorbs the things your body needs. And then you walk around feeling anxious all the time. Maybe it's the fiber. Right?

Dr. Sarah (9:29)

I don't know why anybody wants to go to bathroom. Going to bathrooms like a full time job for them, like fiber, it's like it just makes you go to the bathroom more. It doesn't make you go to the bathroom. So I think people don't understand the gallbladder's role and how actually estrogen in women. You need estrogen for the gallbladder to even work and that helps you go to the bathroom. So as you get older and you start to become constipated, it's not an increase in fiber that you need, it's estrogen that you need in order to go to the bathroom.

Dave Asprey (9:52)

Wow.

Dr. Sarah (9:53)

So this is. Everything's interlinked. I mean, hormones are messengers in the body. They help everything communicate, they help everything function. I mean, if we just look at them as messengers, they're going to help all of the machinery work.

Dave Asprey (10:09)

So when a woman has finished perimenopause and entered menopause, what are the appropriate levels of sex hormones to feel good for the average woman?

Dr. Sarah (10:19)

So I think we out back up a little bit too, because instead of looking at it, menopause is just one day. It's just when your period stops. But we have women in their 20s who have levels of a 90 year old and so we do not need to. The period doesn't mean anything. It's like meaningless. But we keep pigeonholing women into these definitions of perimenopause and menopause and instead we just need to say your ovaries are not working as well as they used to.

Dave Asprey (10:45)

Oh, like that's pretty much every young person right now.

Dr. Sarah (10:47)

Exactly. And so you see the drop off in testosterone in men. The same thing is happening to women. It's like a crisis.

Dave Asprey (10:54)

I'm happy you said that. Dr. Ann Shippey was just on the show with her book on preconception. And yeah, it's not like just men have a drop in hormones from all this environmental nonsense we're doing today. It's affecting Women. And that's why. How old are you? Like you're younger than me.

Dr. Sarah (11:11)

45.

Dave Asprey (11:11)

Okay, cool. So you've got about eight years on me when we were young. When you start dating, like, I hope we don't get pregnant, right? Literally, I know 25 year olds say, like, I hope we can get pregnant. It's been a massive change and hormones are behind a lot of it. So would you recommend, say anyone in their 20s who's having, say, menstrual irregularities get hormone tested?

Dr. Sarah (11:36)

So I think these like pesticides and phthalates and parabens are binding to the estradiol receptor. And then plus we have birth control in the mix.

Dave Asprey (11:44)

Oh, it's just terrible.

Dr. Sarah (11:45)

So birth control is suppressing this hormone function. Birth control is not hormones. It's suppressing it.

Dave Asprey (11:51)

So what do you mean? Of course it's hormones. It's just unnatural hormones that suppress it.

Dr. Sarah (11:55)

You're saying they're just chemicals that we call hormones. They bind to the hormone receptor.

Dave Asprey (11:59)

Okay, fair point.

Dr. Sarah (12:01)

But women, you know, if you have a 25 year old, does she necessarily need bioidentical hormones? Maybe, like if you've eliminated all these chemicals in her environment and she's maybe been on birth control and it's not recovering, then why not? Like the risk of not being on the hormones is greater than being on the hormones.

Dave Asprey (12:17)

Thank you for saying that. I was in a similar situation in my mid-20s. They put me on testosterone under doctor's care and it totally changed my life. And I wish that for every mid-20s man or woman, if your hormones are broken and you fix your diet and you get rid of your scented candles and pine trees and all that kind of pine tree air fresheners, all that crap, and it still doesn't work fine. Like fix it. Get your life back. So I love that you're saying this.

Dr. Sarah (12:43)

And even replacing the hormones prevents, it protects you. So if your receptors are open, right? So you have no hormones, your receptors are open, all the chemicals can bind to them. But if your hormones receptors are full of hormones, then you're pretty resilient against these environmental chemicals too.

Dave Asprey (13:04)

Oh, interesting. Because you have the right hormones in. What do you think about like phytoestrogens as a source of estrogen pollution? Like, should we all just be bathing in flaxseeds, things like that?

Dr. Sarah (13:14)

No, I think that's garbage. I mean, first of all, it's like a weak binding. It doesn't behave like estradiol, which is the really potent estrogen that women need that we know there are Benefits to skin and hair and sex and sleep. Phytoestrogens. Like, I mean, why when you can have the real thing?

Dave Asprey (13:31)

Well, I think that they're actually just hormone disruptors, like flaxseeds. If you want to be fertile, don't eat flaxseeds. Like, they're not good for you.

Dr. Sarah (13:39)

Well, seeds in general.

Dave Asprey (13:41)

Fair point.

Dr. Sarah (13:42)

I mean, it's a trade off like you're trying to gain. You get a lot of benefits from that when you're probably doing a lot of negative things too at the same time.

Dave Asprey (13:50)

So you're saying seeds are dumb?

Dr. Sarah (13:52)

Yes, absolutely.

Dave Asprey (13:53)

Okay. I'm not going to disagree with you. Plants don't like when you eat their babies, so they punch you in the face when you do it.

Dr. Sarah (13:59)

Yeah, I mean, fair. I don't like plants.

Dave Asprey (14:02)

Are you carnivore? Yeah, 100%. Like, you never eat any plants at all?

Dr. Sarah (14:07)

I like fruit. Like, I'll eat fruit every now and then.

Dave Asprey (14:09)

Okay, got it. What about like herbs?

Dr. Sarah (14:13)

Anything that will flavor the meat, I will tend to eat, like chimichurri sauce. The herbs are like any like spices and things like that for the meat?

Dave Asprey (14:23)

Absolutely. Okay, cool. I always laugh because people. I have to eat my kale because polyphetols and I'm like, bad at math because if you have rosemary and oregano and herbs like that, they have thousands of times more polyphenols than eating whatever vegetable. I'm not saying you shouldn't ever eat any vegetable, but a lot of them are just not worth it. And especially if you're dealing with hormone dysregulation, getting rid of excess plants and replacing them with high density protein and fat kind of seems to work, right?

Dr. Sarah (14:53)

It does. I do think that it's important that women understand that it doesn't replace the hormone replacement therapy. So I think a lot of functional medicine and longevity doctors will promote this. Just change your diet. Just fix your leaky gut, lower your cortisol. If you switch to a carnivore diet or a vegan diet or whatever the diet is that they want you to switch to, then you will balance your hormones. And I think this is not like dangerous, but it's profitable. And women are suffering for years because of it. It's garbage. Like, they need to replace the hormones and then use the diet and supplements

Dave Asprey (15:23)

and everything to further optimize with unlimited.life, which is the concierge longevity practice that I'm working with. We have $40,000 worth of lab. It's like we know everything about you and we work with you for a whole year. And the women in that program who get on hormones quite often, even though they're very successful, have expensive doctors. They're not getting hormone replacement because the doctors just haven't heard the latest news, or they're getting a little patch that doesn't work. And when we test their levels, you can see it doesn't work. And then we change how they're getting it. And it's like watching. Like, it's like watching when you water a plant that needs water, like, it just comes to life. That's the effect on the brain. So what does estrogen do for women's brains?

Dr. Sarah (16:12)

Both estrogen and progesterone help with the brain. But, I mean, you can. Even so, again, if you think of a hormone as simply a performance molecule, all the machinery is there. It helps the body communicate and work properly. Like, so, for example, that's how we use hormones. So I think people think that they're more. You know, they are. They're the foundation. So your liver, for example, it doesn't see the outside world. It doesn't know that you just ate that donut. It relies on insulin, the hormone, the messenger, to tell you tell it that you just ate that donut. So every specialized cell in the body relies on the hormone to tell it something. So the brain is no different. So, for example, we have at night, when you're sleeping, the cerebral spinal fluid cleanses the brain, even with the help of estradiol. So estradiol and progesterone are orchestrating everything. It tells the immune system what to do. So there's not just, like, noise, there's actually, like, music going on in the body. This is what the hormones do. So you can imagine that nothing actually will function without the hormone. Mitochondria won't function. I mean, so the very, very basis, the foundation of health and wellness and longevity is hormones, because it helps the machinery. It tells the machinery what to do.

Dave Asprey (17:23)

Okay, there's a lot of companies marketing testosterone to men for libido, and a lot of companies marketing testosterone to women for libido. What are the pros and cons of testosterone for women?

Dr. Sarah (17:36)

Yeah, I think women need testosterone just like men need estrogen. Estrogen is very beneficial for men, so we know the same for women. The problem is that the way that they're trying to get testosterone into the body, when you put testosterone on the skin, it converts to dht and it will make your hair fall out if you inject it. Women have high aromatase enzymes that converted to estradiol yeah. Injecting testosterone feels much like a manifest, the ultimate manifestation of be like a man. Like, be like a tiny man, which I'm not just like a tiny man. So I think libido, we tend to take what we know and we extrapolate for men and we extrapolate it to women when we just assume that we have the same drive or sex drive as a man. And I think this is unfortunate because the egg does not go towards the sperm. The egg sits and is very receptive. I mean, women's libido is receptive and open and there's connection and bonding and safety.

Dave Asprey (18:38)

I think you might not know some

Dr. Sarah (18:39)

of the women I know there is that part too. So you can have the drive and you can.

Dave Asprey (18:43)

But I'm just kidding.

Dr. Sarah (18:45)

I think women need to have all of that in order to feel like that. But the receptive part is really important. And testosterone will never give you that. So although you can have. I prescribe it to some. When I used to prescribe it, I'd have patients tell me, well, I was with my family kids in laws on testosterone, and I felt like masturbating all day long. She's like, is this how men feel? This is awful. And I was like, yeah, I think

Dave Asprey (19:12)

that's pretty much how men feel when they're healthy. Yeah.

Dr. Sarah (19:15)

So I'm not sure that women want that drive all the time either. So maybe matching what their natural libido should be is what we should be looking at and trying to understand that more.

Dave Asprey (19:24)

It feels weird to put a gender on these hormones because women need four times more testosterone than estrogen, because estrogen is really strong and testosterone isn't as strong per unit, and men who don't have estrogen have much higher risk of heart attacks and. Right. So if men need estrogen and testosterone and some progesterone sometimes, and women need both as well, trying to, like, dress one of them up in a pink dress and other one in, like black kettlebells, it kind of just doesn't seem scientific or even reasonable.

Dr. Sarah (20:00)

You're totally right. I mean, I agree with you. And it's also. If we just look at them as what they are, they're not sex specific necessarily. So I think the ratios matter. Like, women need 10 to 30 times more progesterone than testosterone or estrogen, for example. And this is the one that modulates and controls a lot of the. And tones down some of the stimulatory effects of estradiol and testosterone have in the body for women. But libido the limbic system is flooded with estradiol receptors. Estradiol behaves like mdma, for example, too. It creates this kind of receptive nature. Yes, there's testosterone receptors vaginally, but in reality, progesterone and estradiol are foundational to women's libido. And we do not give them any credit. We think that testosterone for both sexes drives libido, and I think we need to give credit where it's due for estrogen.

Dave Asprey (20:53)

It's kind of like having the right recipe for libido, right? You've got to have the right balance of ingredients, and it's not just one thing. And it's kind of like if you wanted to make bread, you can't do it with just flour, Right. But it's an ingredient. So let's talk more about libido, because what I've heard from the women in, well, just over the many years I've been talking about hormone replacement, but specifically when I have access to their labs and we're working with the doctor, especially women over about 45, they're like, oh, my God, I feel like myself again. I'm enjoying sex. And before that, they're kind of like, it just went away. Like, I used to like it, and now I just don't really have any desire for it. And then they get on the right balance, and all of a sudden they don't hopefully want to masturbate all the time unless they're into that. But they're just like, my relationship is so much better because, like, I have desire again. And what's causing that?

Dr. Sarah (21:53)

Yeah, no, it's. So dopamine can cause some of that. Where estradiol modulates dopamine, norepinephrine, and also serotonin. When these all work together, you can have libido. So there is a component where you can optimize hormones in women. Testosterone, estrogen, and progesterone. And she still won't have a libido. And you do need to look at these neurotransmitters in this ratio and probably get dopamine and norepinephrine to be. To elevate. And this is where you can optimize further.

Dave Asprey (22:23)

And that's an L. Tyrosine, rhodiola, kind of a problem.

Dr. Sarah (22:26)

You could. Or Sami or diet change or increasing protein intake. Since we need protein to make dopamine. A lot of women do not eat enough protein. Like, I know that there's. It's really big right now, but it's true, like, the most women are starving themselves to lose weight, and they don't eat the protein, and then they get low dopamine.

Dave Asprey (22:45)

There's nothing sexier than a woman eating ribeye. It's just a fact. Like, ask any guy. And I feel so bad. There's a lot of, oh, I'm on a date. I'm just gonna have a little salad and a little pasta. And it's like, no. Like, you eat that steak and, like, just enjoy it. And then, like, get powerful. And the guy you're with will be like, that's a real woman. Like, it's good. We don't have a problem with that. Women. Because you're wondering about that. Yeah. And by the end, if the guy does want you to starve yourself, get a better guy. Like, come on.

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Dave Asprey (24:21)

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Dr. Sarah (25:37)

But I think we can also to help women more with their libido is recognize a physical sign. So for example, when we put men on testosterone, an erection is like an obvious thing. Yeah.

Dave Asprey (25:47)

You wake up with a kickstand, right?

Dr. Sarah (25:48)

Yeah. Right. Yeah. Never heard of that called before. But it's great.

Dave Asprey (25:54)

Women have it too. It's called a morning bean.

Dr. Sarah (26:00)

Hairy.

Dave Asprey (26:02)

Love it.

Dr. Sarah (26:03)

But yes. So like this physical attribute, you know, with men it's easy, it's blood flow. So you know that that's like a vital sign that they're healthy.

Dave Asprey (26:11)

Right.

Dr. Sarah (26:12)

With women, blood flow is responsible for vaginal lubrication, which is when you put them on appropriate hormone replacement therapy. You should see this. And if you don't, it's like having multiple. But women not only do, there's some shame around it, but they feel, I don't think we're taught from a young age we know more about men's bodies, for example. So I have some 60 year old women, they're like, I feel like I'm 13 years old again. That's how it's supposed to be. Right. So you're supposed to get that back.

Dave Asprey (26:41)

And maybe some nitric oxide support for women too. We do that, we see it a lot in labs. So a lot of our clients are on nitric oxide boosters, whether it's 5 milligrams of Cialis at night for men and women because it's also anti Alzheimer's or the more natural compounds like Vasconox and 101 or any of those kinds of things.

Dr. Sarah (26:58)

And you can do it or you can, can raise estrogen more for her. So estrogen.

Dave Asprey (27:02)

And that'll just turn on nitric oxide.

Dr. Sarah (27:03)

It does okay.

Dave Asprey (27:04)

Even if you don't eat like toxic beets or anything.

Dr. Sarah (27:06)

It does okay. Like I mean really like I think again this is further optimization that you can do with those. But I think ultimately she's not optimized with her estrogen and progesterone and testosterone levels. Like this is really the crux of the problem is that we keep throwing, we keep treating like each, you know, engine part instead of looking at like the ignition or looking at from a hole. So if I kept you at 100 of testosterone and then I kept telling you to take more Viagra, more of this and change your diet, I'm just having you spin your wheels for years instead of just getting your Testosterone up to 1000 or 1500 or even more, whatever you feel good at. We don't do this for women.

Dave Asprey (27:47)

Oh, gosh. We don't do this for men either. Well, okay, you know how a few doctors are going to say let's give you enough testosterone until you like feel like yourself again and wake up with an erection? They're just like, oh, 700. That's kind of high. Like, not for that guy. That guy needs 1200 and that guy needs 600 in order to feel.

Dr. Sarah (28:03)

Right.

Dave Asprey (28:03)

The range is very big. And it's very different for women too. Right. Like, some women need way more than others to feel like they're in their bodies again. Right.

Dr. Sarah (28:12)

There's genetics at play. What genetics comt is like epigenetics. I mean, it's big. So some men. So if you Even men or women that fall off earlier, potentially in their 20s, like looking back, I probably had problems in my 20s. These individuals have the machinery and the methylation because we have to remember that we don't actually get rid of estrogen and hormones through the liver. They're methylation pathways. We methylate the hormones and get rid of them. So if we have a methylation problem or we methylate faster. So I think we also think that it's slow, but it's not. Women and men get rid of dopamine, testosterone and estrogen really fast. And then you'll see these levels lower on labs too. They need more or they need to change their diet. And you can change. This is where the diet really does help these individuals too.

Dave Asprey (28:58)

So what are the most typical dietary changes other than not eating? Tons of fiber.

Dr. Sarah (29:03)

So the fiber is actually huge. To reduce that. But the more protein intake you can do does overwhelm the comt pathway and slow it down. So individuals with a fast comt gene, if you increase protein intake, you can keep your estrogen a little bit longer, keep your testosterone a little bit longer, they will notice that they feel better, they feel more focused, they feel more calm. They feel like their testosterone can last that 24 to 48 hours till their next dose or whatever. So this is the biggest dietary change that people can do. That's not so simple for people. Yeah, but it is actually that simple. If you were to do this, you'd

Dave Asprey (29:40)

feel a Lot better step away from the metamucil is what you're saying.

Dr. Sarah (29:43)

Oh, my gosh. Yeah. Like the.

Dave Asprey (29:45)

Yeah. Now there's two kinds of fiber, and I want to draw a difference here. There's soluble fiber, which I'm kind of a fan of. I did a bunch of tests on it for my longevity book. And then there's insoluble fiber. What's the difference?

Dr. Sarah (30:00)

Well, I think that soluble tends to be better in that it's not going to. It's like that heavy fibrous, like insoluble that you're just.

Dave Asprey (30:08)

That's what steals all the stuff, fueling

Dr. Sarah (30:09)

this bacteria in the lower intestine that's not supposed to be there and causing a lot of the bloating and SIBO that we see. Like 90% of people have SIBO. Now, that's not bacterial overgrowth. And then when you start hormone replacement therapy, it's even worse. So both men and women get even more bloated when they start the HRT

Dave Asprey (30:26)

because of too much soluble fiber. You're saying? Yes, got it.

Dr. Sarah (30:29)

Because you're basically just feeding. And if you think about meat, the fiber in meat, these medium chain fatty. That is fiber for the bacteria, that's all the fiber you need is if you just eat the fibrous meat instead of ground meat or whatever.

Dave Asprey (30:43)

If you're eating fibrous meat, I kind of turn collagen into a billion dollar industry. And yeah, they call collagen animal fiber because it's fermentable. In fact, in the bulletproof diet, I, as far as I can tell, it's the first book that published research showing that gut bacteria can turn collagen into butyrate and other good things. Granted, those gut bacteria were in a leopard, but they're also in people. So there's that.

Dr. Sarah (31:08)

Yeah, no, I mean, it's amazing.

Dave Asprey (31:10)

I do find there's a benefit to having some amount of soluble fiber for bacterial diversity. But you don't need excessive amounts of it.

Dr. Sarah (31:18)

Right. It should be like reasonable. We're just overdoing it.

Dave Asprey (31:23)

And soluble fiber also won't steal your hormones because it gets metabolized by bacteria in the gut.

Dr. Sarah (31:27)

Right, Right.

Dave Asprey (31:28)

Okay. So no more sawdust, roughage, whole grains, they're all dumb. Eat white rice there, I love it.

Dr. Sarah (31:36)

You'll be better, but do hormones and then that.

Dave Asprey (31:39)

Yeah, you should probably do both. Okay. Now if, say, mid-20s woman's listening to this, she's going, well, I've been feeling different. I'm noticing changes. My cycles are regular or it's not happening and all this. What's our first step?

Dr. Sarah (31:53)

So for any woman, I mean, the first step is recognizing that there is, if you have more than one thing going on, that this is most likely hormonal, not mitochondrial. So at the base of it though is hormones. So if your mitochondria are not functioning. Longevity. People love mitochondria.

Dave Asprey (32:12)

I kind of have a mitochondrial fetish.

Dr. Sarah (32:14)

Oxidative stress. It's like so sexy. Inflammation, ATP. Like, they just love it.

Dave Asprey (32:20)

They talk dirty to me.

Dr. Sarah (32:22)

I love it too. Right. But your mitochondria are not actually going to function or regenerate or work properly without your hormones.

Dave Asprey (32:29)

Correct. They're hormone responsive and they make some hormones too. Right. It goes back and forth. And so chicken and egg situation.

Dr. Sarah (32:37)

Yes. But we're seeing women with like autoimmunity, which we carry the bulk of that, like 80, 90% of it. So the immune system is like an energy hog. It needs a mitochondria in order to work. And also the B cells and T cells are going to be really chaotic unless the hormones are helping it tell it what to do. So you won't see like these traditional perimenopausal symptoms in younger women. You'll see autoimmunity. She'll get Hashimoto's lupus, like some food sensitivities. They start messing with their diet a lot. They have leaky gut. They won't love their skin and hair even. So they won't be sleeping. They have a lot of anxiety. We put women on antidepressants and samples.

Dave Asprey (33:14)

Which is bad for your mitochondria. Yeah.

Dr. Sarah (33:16)

So I think that we can look at these. We look at these really traditional symptoms for women. Again, we're kind of pigeonholing them instead of just being like recognizing the health that is not at its optimal state. So the 25 year old, if she just doesn't feel like she's healthy, hormones do need to be looked at. Labs are not going to help because we have not established appropriate reference intervals for labs for women. There are like five papers in the entire world, five on what? If you were to say, what is the optimal reference range for progesterone for women? This does not exist.

Dave Asprey (33:51)

It totally exists.

Dr. Sarah (33:51)

People ignore it.

Dave Asprey (33:52)

You don't know about this. The answer is really easy. It depends.

Dr. Sarah (33:56)

Some of these, like progesterone, I didn't even order that. Like it's literally never even ordered.

Dave Asprey (33:59)

It's wild. It's crazy. They don't order it. And one of the reasons they don't order it is because if you don't know what time of day and where in your cycle you wear, and a lot of women don't necessarily even track that, where they are in their cycle, then progesterone and the other sex hormones, they aren't that useful because there's these wide circadian and month long swings. So establishing a reference for day seven. Okay, but then within a group of women, the variance can be really high, right?

Dr. Sarah (34:29)

Yes and no. Okay, like I get what you're saying. I hear you.

Dave Asprey (34:32)

I'm not justifying it. I'm just saying that's why they haven't done it, because it's expensive.

Dr. Sarah (34:35)

Yeah, yeah, well, and then also there is that variability, but it's not that hard. So I would blame it on the lab community that they, oh, 100%, you need to do this. We can do this, guys.

Dave Asprey (34:46)

You'd have to actually, on the lab form, you'd have to change a field and ask women what time of day where in your cycle and all that. And it's just complex and operationally they don't want to do it, but they should.

Dr. Sarah (34:58)

We should. And we also can do it at a peak ovulation time, which is day 10 to 14, which we know that everything should peak. Right. So we kind of know that if she is ovulating. So that's one way. Another way is to get an FSH. So this is a measure over 30 days and this is what your brain is telling.

Dave Asprey (35:15)

So let's define that for the audience.

Dr. Sarah (35:17)

So FSH is follicular stimulating hormone.

Dave Asprey (35:20)

And men and women both have it.

Dr. Sarah (35:21)

They do. So, like what happens is if your ovaries in a female are not functioning like they should. So basically fatiguing doesn't matter what age you are 18 years old for whatever reason, and then the brain will start to panic, releases FSH to stimulate the ovary to make more. So you'll see this get higher and higher. If the body is struggling to make the appropriate amount of hormones. So you can follow this, even just like a small tick can indicate it, we follow it for thyroid, thyroid stimulating hormone. We know these other processes and feedback loops exist in the body. Once we know that our FSH is rising, we can, if you put her on the hormone replacement therapy, it will suppress her own production, which is okay because within women it can be really erratic because maybe the ovaries will make like a spike of estrogen, but they can't make their primary hormone. And this is where you'll see like some of that roller coaster ride that she goes on. So instead to even her out completely, let's suppress fsh, like give her everything. So the problem is we'll look at a 25 year old and be like, you just need a little bit of progesterone. So instead of giving her everything, we give her a little bit of progesterone. It still suppresses the fsh. And then she feels like shit still because you're not giving her everything that she's not making. So this is like one hormone approach that we really take with women is also hurting them.

Dave Asprey (36:39)

Okay. How do you like to get these hormones into women?

Dr. Sarah (36:44)

So we mentioned how bad oral and topical patches are.

Dave Asprey (36:48)

I've seen oral progesterone work pretty well, but not for estrogen.

Dr. Sarah (36:52)

The reason why oral progesterone works is because those toxic liver metabolites just make you sleepy.

Dave Asprey (36:58)

What are they?

Dr. Sarah (36:59)

Allopregnanolone is one of them. And a lot of them are anesthetic. So they just. A lot of them, we don't know what they are. They just put women to sleep, which she starts to feel more calm. It's binding to some of the GABA receptors. So she does feel this sense of like a Xanax. So she's like, great, I can stop my Xanax and stop some of these supplements. So this helps. But are you doing the. Can you imagine if she felt good? So if you give her 200 milligrams of that, she's only really getting 20 milligrams because the rest of it's like

Dave Asprey (37:29)

I don't see pregnenolone and allopregnanolone high on the labs of the women on oral progesterone.

Dr. Sarah (37:36)

So there is cross reactivity on the labs as well. So we're talking about an immunosay, which I know nobody knows what that is and I know what it is because I.

Dave Asprey (37:45)

Sure.

Dr. Sarah (37:45)

But when you test progesterone on oral progesterone and it's high, it's because these metabolites cross react on the lab test and you're going to get faulty elevated.

Dave Asprey (37:55)

So allopagnenolone tests as progesterone can cross react on the.

Dr. Sarah (38:00)

Unless you do like a mass spec or something more accurate, which you can. And they're more expensive tests. But in general we're not using that. As for hormones and we don't have so much. I think you're right. We have to talk about bioavailability.

Dave Asprey (38:14)

Yeah, patches generally don't work. Like everyone in our group who is On a patch with progesterone, it's like, why it doesn't do much. Yeah.

Dr. Sarah (38:24)

And then pellets have a problem in that you can kind of creep up and they tend to make you testosterone dominant. So you're like, great. I feel great at first. I have a libido. I'm starting to feel better. And then you just keep raising that and all of a sudden you're voice starts getting deeper and starts getting deeper.

Dave Asprey (38:39)

It seems pretty. I haven't seen that, but I mean, I know it happens, but it seems like it's pretty ideal.

Dr. Sarah (38:45)

You have to get high.

Dave Asprey (38:46)

Okay.

Dr. Sarah (38:46)

Yeah. So to be fair, like, you can tolerate quite a bit of that before that change happens.

Dave Asprey (38:52)

And for listeners, we're getting kind of nerdy. Understand that there's kind of. There's two sort of mother hormones, and they're DHEA and pregnenolone. And in men and women, they can go down different pathways to different kinds of estrogen or testosterone, depending on genetics and environment. So when you take progesterone, you're basically affecting the ratios of everything because it's like a mother.

Dr. Sarah (39:14)

It's like it converts downstream.

Dave Asprey (39:16)

Yeah. So if your progesterone consumption increases pregnenolone and then pregnenolone turns into testosterone, that might feel really good. And it might be a good thing if it's the right dose or it might be too much.

Dr. Sarah (39:27)

Yeah, exactly. But the best way to probably get into the body. So when I was going through it, and when you're a younger patient, you tend to need more. I don't know if you noticed that, you know, in your 20s and 30s, because our bodies are younger, we do need more hormone. We need more of the messenger, we need more of the performance.

Dave Asprey (39:45)

Yeah, you should have more. And I believe after a long time in longevity, when you're old, you also should have a young person's levels if you'd like to maintain your youth. So the idea that, oh, you have the right levels for your age, like, for your age, is a curse. Words that should not be said. It's for the age that you would like to feel like is what we should be treating 100%.

Dr. Sarah (40:06)

Yeah, thanks for saying that too. Because it's the formulations for women like the patch and the pill. They were designed for 55 years old and above. They were designed to get you through menopause, give you a little bit of relief, get you sleeping, get rid of some of your vaginal dryness. We have like talk about vaginal cream in a second. But then it was truly meant to be like a year just to help you through this like transition. That's how we view this for women. We don't view it as like a longevity or foundational. And so that's the problem is that we need to all switch the way we think about it. So if we think about it differently, that it's not that it is an optimizer, it is for longevity, it's for to feeling more youthful and the best

Dave Asprey (40:46)

you can do, not get Alzheimer's, not get diabetes, heart disease, all the stuff that hits women if they don't have enough hormones. Geez.

Dr. Sarah (40:54)

So it's a no brainer. So instead of waiting till you're 55 and giving you these little tiny doses, which is what we do, this is like how even longevity doctors and hormone replacement doctors think about it. So we need to completely like change, like flip everything over and look at. Okay, a 30 year old needs hormone replacement therapy. A patch and a pill won't work. It's not enough. It's not getting into the body enough. So how do we get her levels up to 1000 or 500 or whatever

Dave Asprey (41:18)

she needs to be at of which one?

Dr. Sarah (41:20)

All of them. Okay, so vaginal delivery, you know, vagina I guess is like another superpower. Like it's a superpower for women.

Dave Asprey (41:27)

Yeah.

Dr. Sarah (41:27)

But we tend to think of vaginal delivery as local only. And it's because of these FDA approved low dose vaginal creams that are tiny, tiny doses. They were meant just to treat vaginal dryness. They were never meant, they were never designed to go systemically because the dose is so small. So you raise the dose and it does. The vaginal wall is porous, it goes right into the bloodstream. Not only that, you get a first passed metabolism through the uterus, which is where the hormones probably should be metabolized. The uterus makes special metabolites, that's what's controlling that instead of the liver. I mean it's. Again, we're getting nerdy. But this is so important that people understand that not only do the hormones matter, the types of hormones, the ratio, the formulation, the metabolism, I mean these are going to impact how you feel on hormone replacement therapy.

Dave Asprey (42:19)

So you're a fan of vaginal delivery

Dr. Sarah (42:22)

of both progesterone and estrogen.

Dave Asprey (42:24)

Okay, and what about testosterone?

Dr. Sarah (42:26)

So if you put testosterone vaginally, you can disrupt the microbiome.

Dave Asprey (42:30)

But it's so much fun.

Dr. Sarah (42:31)

It is so much fun. And it's okay for temporary or it's okay for like. It is actually like, fine to do as a spontaneous, like, thing every now and then.

Dave Asprey (42:38)

They call it scream cream.

Dr. Sarah (42:39)

Exactly.

Dave Asprey (42:40)

You put a small amount of testosterone around the labia on the clit, and you'll see blood flow like you've never seen before and your toes will curl.

Dr. Sarah (42:50)

It's pretty fun. Yes. And so this is like a. But if for an actual daily or twice daily treatment, you can really disrupt the microbiome this way.

Dave Asprey (42:59)

So have you tested that, like with ev or something or so?

Dr. Sarah (43:02)

No, but we have a lot of studies on transgender patients, for example, so, like, we know we have.

Dave Asprey (43:07)

Actually, that's a pretty different microbiome. Is that like colon tissue? Anyway, like, that would be.

Dr. Sarah (43:11)

No. For women.

Dave Asprey (43:12)

Oh, women.

Dr. Sarah (43:13)

Yes.

Dave Asprey (43:13)

Okay, Got it.

Dr. Sarah (43:14)

So. But we given testosterone.

Dave Asprey (43:16)

Okay, I see.

Dr. Sarah (43:17)

And we know. Well, we actually have more papers on this than we do for women, which is kind of embarrassing too. So. But so the microbiome and testosterone, we actually know what's gonna happen there. But there's also a problem that if you're looking at her long term and you give her that much testosterone exogenously, that it will get too high. So how do you just let the body control how much testosterone's made? Like, for men, I give you test, I give you. I don't give you estrogen.

Dave Asprey (43:43)

Why not?

Dr. Sarah (43:44)

Well, I know you need it, right. So why not just have you inject it?

Dave Asprey (43:47)

Actually, I've looked at doing it doing like a very small dose with an injection, but I just put it on my face.

Dr. Sarah (43:55)

Perfect. I love that. Such a good idea.

Dave Asprey (43:58)

Yes. Guys, I'm very feminine. I used some estrogen, actually.

Dr. Sarah (44:03)

For your face?

Dave Asprey (44:03)

Yeah. There's like 0.1% or something in my facial stuff.

Dr. Sarah (44:07)

Yes. Not. It's very smart, actually. It's really smart. But no, because testosterone in your body is converting to estrogen, so you don't need to worry about it.

Dave Asprey (44:16)

Well, it depends on your genetics.

Dr. Sarah (44:17)

Sure. But even I've seen men get up to 70, 100, like a little bit even higher than that and have great skin.

Dave Asprey (44:24)

Oh, yeah.

Dr. Sarah (44:25)

Look great, feel great. And they don't need to lower that estrogen at all.

Dave Asprey (44:28)

As long as you don't get man boobs.

Dr. Sarah (44:30)

Exactly.

Dave Asprey (44:30)

That's good.

Dr. Sarah (44:30)

So it's actually just the tenderness.

Dave Asprey (44:32)

It's been a problem for me for many years. All the guys in my family. In fact, my grandfather, before he passed, he's like, should I have these things taken off? And finally he's like, that's it. I'm getting a bro. And he literally was wearing some kind of tank Top thing to just hold him up. And I'm like, I'm not going there. And I had a lot of sensitivity about that when I was in my teens and twenties. And since I got my testosterone and my estrogen levels where they're supposed to be, I haven't had surgery and I don't have man boobs, and I'm the only guy in my family like that. It's kind of cool.

Dr. Sarah (45:03)

It was cool.

Dave Asprey (45:04)

Yeah.

Dr. Sarah (45:07)

So that is a caveat, like, depending upon your genetics. But there are things you can do to kind of lower that estrogen. So we can block that or we can give herbs. Well, aromatase for you. For men, for example. So there are ways that we can.

Dave Asprey (45:19)

Which herbs? I'm talking about.

Dr. Sarah (45:20)

Oh, herbs. Oh, to lower. Well, you can use. So it's, again, dim is hard because it's actually like in the liver. But there's iodine is actually the best way we could talk about.

Dave Asprey (45:30)

Interesting. So dim, I don't know. See a lot of results. I don't think it's that good for you. Crisin is very effective, at least in my experience. Yeah. Just ferment to lower estrogen. And then for men and women, calcium D glucarate can be magical.

Dr. Sarah (45:46)

But we don't want. So let's go back to. We don't want to lower estrogen necessarily, men in women, because we're trying to raise that one. So let's.

Dave Asprey (45:52)

It depends if it's the toxic form of estrogen, if you have the genetics to make for deoxy, which about 20% of the women in unlimited life make toxic estrogen. So they have to clear it faster and bring more clean estrogen in at the same time.

Dr. Sarah (46:07)

And the problem is, like, trying to get that clean estrogen in, like, I think is the challenge that we're having. We have better ways of getting rid of it, eliminating it. But I think to draw the analogy to women, progesterone converts to testosterone in women. So give her enough progesterone.

Dave Asprey (46:23)

Interesting.

Dr. Sarah (46:24)

And let it convert. And her genetics will. So if she makes too much testosterone, which a certain percentage of women, just like men. Men make too much estrogen. Women are going to make too much testosterone, and then you'll see their hair start to shed or they'll start to gain weight or get irritable. Those are like the main symptoms of too much testosterone. And this you can just lower and block with supplements.

Dave Asprey (46:43)

And the most important piece of advice I would have there for women is treat the symptoms, not the numbers. So my former Wife and mother, my children in med school.

Dr. Sarah (46:54)

Her.

Dave Asprey (46:56)

Her doctor friends when they ran the labs and like, why do you not have a mustache? And she's very feminine. Right. She said, what do you mean? She said, well, your testosterone levels are exceptionally high, and it's a genetic thing, but if we were to treat her labs, then we would not get any results because she doesn't have an average number to feel good. Right. So her body requires that. And there's lots of women out there where the range is variable. So you have to feel good and not have the symptoms. And we can tweak it until then. Right.

Dr. Sarah (47:22)

100%. And it's not only the level, it's the ratio. So your wife, your ex wife could have had plenty of testosterone, but her estrogen and testosterone were also elevated as well.

Dave Asprey (47:32)

She had to manage all of the hormones, you know, in her own way.

Dr. Sarah (47:35)

Yeah, but like, she. So it's like if they were. It's fine if the testosterone. If the problem is if it's the dominant one, and that's not supposed to be. And then you get the symptoms.

Dave Asprey (47:45)

Yeah.

Dr. Sarah (47:45)

It doesn't really matter what the absolute level is.

Dave Asprey (47:48)

That's the big lesson here, is don't treat the numbers on the lab, especially because, as you said, we don't even know what the right numbers are. But if you don't feel good, then let's tweak it until you feel good. And feeling good means, wow, I'm wet sometimes and it means, wow, I like my life and my brain works. I'm not inflamed. And, like, you can feel what wellness feels like versus not wellness. So to help women here, what are the symptoms of low estrogen that they would feel first?

Dr. Sarah (48:18)

I think we can mention that it's low hormones, since we don't. So we have a problem too, of like, oh, this is an estrogen problem. Like, you have vaginal dryness.

Dave Asprey (48:29)

I'm going to ask you about all three. Right.

Dr. Sarah (48:31)

But I mean, like, maybe look at it as they all work together on even the same thing. Like, if your blood pressure, you need all of them in order for that to work. So libido, you need all three of them. So it's not just like, oh, you're low in testosterone and that gives you a symptom.

Dave Asprey (48:43)

I wasn't asking about specifically libido here. I don't know. You seem obsessed with that. I'm not going to.

Dr. Sarah (48:50)

No, I'm just saying, like, I know you're getting that, like, hey, what, what sign. But I think in General, what symptoms? Like if women are not making the hormones they need to. What symptoms?

Dave Asprey (48:57)

Okay, so let's put it that way. So give me in order, the symptoms that a woman would notice when her hormones are loud.

Dr. Sarah (49:05)

Yeah, thanks. Sorry. I think the most common that younger women have are like mental, like anxiety and irritability and like a mild depression. So we even see this with all of the antidepressants and Xanax that are prescribed. And women will notice this first. I feel like I'm going crazy. I don't feel like I'm in control of my emotions or they feel very like. And they don't even have to have sleep disruption. They just feel this underlying anxiety.

Dave Asprey (49:32)

Wow. So you would put women on vaginal hormone replacement before you'd put them on SSRIs.

Dr. Sarah (49:38)

100%. Are you kidding? Yeah.

Dave Asprey (49:40)

Wow. I love that you're saying that. I don't disagree.

Dr. Sarah (49:43)

Yeah, like why, I mean, why would we lean towards something that's really hard to get off of? We don't know what the long. We actually have more long term studies on hormone replacement therapy than SSRIs.

Dave Asprey (49:52)

Yeah, they're not good.

Dr. Sarah (49:53)

And you're all. Yeah, and you're, you're going to get more benefits around the whole body, whereas the SRI is just going to manipulate the serotonin level. But what about everything else, like your norepinephrine and dopamine and I mean, just, even, just than, you know, within neurotransmitters. No, no, no, definitely. Women should consider hormone replacement therapy before that. And then also I would say that like, gut stuff happens really early. So they'll start getting this like, bloating food sensitivities.

Dave Asprey (50:21)

Isn't that like leaky gut?

Dr. Sarah (50:22)

And then they start trying to chase their diet. And they'll chase their diet for years and they'll go to functional medicine doctors and the doctors promote it. So you're saying just keep chasing this diet.

Dave Asprey (50:31)

A primary cause of leaky gut is low sex hormones.

Dr. Sarah (50:34)

Yes, that is the cause.

Dave Asprey (50:35)

I would say a lot of people have said that on the show.

Dr. Sarah (50:37)

Okay, well, everybody says that. Oh, fix your leaky gut and then you'll fix your immune problem. You'll fix your autoimmunity, you'll fix your hormones. Let's say they say the leaky gut is the problem, but you have. The leaky gut is caused because the hormones are missing. Estrogen, estradiol and progesterone make mucin. They can make sure that the gap junctions are closed. They tell like, again, they're Telling everything what to do. So your gallbladder doesn't even function for women unless you have estrogen. I mean, literally, your digestive system stops working.

Dave Asprey (51:06)

Wow.

Dr. Sarah (51:07)

So they start chasing this.

Dave Asprey (51:09)

In menopause, though, women have very, very low estrogen, and they all have digestive problems. Isn't that interesting?

Dr. Sarah (51:15)

Yes.

Dave Asprey (51:16)

Okay.

Dr. Sarah (51:17)

But it starts much earlier. So, like, women. And you see women in their 30s chasing their diet like, I can't eat what I used to. Not that we need to eat like we used to in our 20s anyway, you know, we should change and have a better diet, too. But this is what they attribute to something else. They'll say, it's, oh, I'm gaining a little bit of weight, and now I can't get that off. It must be because of my diet or I'm tired or the kids, or they have 100 things to blame it on instead of, you know, you're not making any hormones. You can't even lose weight without the hormones. So these are not usually. We're like, oh, hot flashes, vaginal dryness, insomnia. These come later. Like, women need to understand that if you have hot flashes, you've waited about a decade too long. We've waited way too long.

Dave Asprey (52:01)

What percent of divorces are caused by low hormones?

Dr. Sarah (52:04)

If I had to guess, Like, a lot.

Dave Asprey (52:07)

Yeah, it's a lot.

Dr. Sarah (52:08)

I mean, it is a lot in

Dave Asprey (52:10)

men and women, to be clear.

Dr. Sarah (52:11)

Yes. Like, in men, the low testosterone cause depression, too. It also causes, like, irritability. And Everybody. No, it. 100%. I've. I've had clients come and sit in my office and say that it's starting to impact their relationship and they know it. And then they start to act on it. And then they come back in and they're like, my husband doesn't irritate me anymore. There's just such this baseline irritation, you know, like, that they couldn't stand him anymore, and then they got on the hormones and they're like, he's fine. He's like. He's just like, you know what I mean? Like, it's not him.

Dave Asprey (52:40)

It wasn't him.

Dr. Sarah (52:41)

It never was him. It's actually a problem that we don't recognize enough. And then we treat men with Viagra and, you know, testosterone too. We're not treating women. And so we're setting the relationship up for turmoil.

Dave Asprey (52:56)

I recommend with 100% certainty, if one partner goes on hormone replacement therapy, you have to put the other one on, because otherwise, if you've reached in a relationship, like, kind of a plateau Like a stable equilibrium where you're both, eh, you know, we're kind of roommates and like, things are good. And then one of the two is like, I will eat you alive. It's not going to end well unless you're both like, I'll lead you back. And then it's like, you know, it's good. And that's actually something that keeps. Yeah. And it keeps you together for a long time. The really successful agers who I've worked with over the years, including in their 80s, like they love each other, but they also have active sex lives and they're supposed to when they're healthy and they're going to live a long time because otherwise what's your motivation for a living long time anyway? Like life is boring and dry. It's not a good thing. So that passion, yeah, libido is a part of that. But libido is also in the East. It's chi, it's life force energy. And if you're not feeling that, maybe fixing your hormones and your mitochondria might be worth doing. Okay, so you mentioned that you don't use testosterone vaginally except when it's for recreation night. Where do you get testosterone for women? What form do you like?

Dr. Sarah (54:15)

Like, well, so I think if you just, if you give her enough vaginal progesterone, she will convert and make and raise her testosterone levels to at least normal to that 30 to 50 range.

Dave Asprey (54:26)

And you've seen this in 100% patients.

Dr. Sarah (54:27)

100%. Tens of thousands of patients at this point.

Dave Asprey (54:30)

That is true.

Dr. Sarah (54:30)

Tens of thousands.

Dave Asprey (54:32)

Wow.

Dr. Sarah (54:32)

Of patients. So like this is, this is not like a theory. I think what again, on top of that, it's like, it's if a woman comes to you and her testosterone levels are normal and she's like, I still am missing what she expects. What do you expect? I think it's also a level of expectation. I expected a greater libido and this is really when testosterone comes up.

Dave Asprey (54:52)

Okay.

Dr. Sarah (54:53)

Okay. So let's hope that, like, how do we manipulate that? How can we raise it? There's plenty of supplements that raise like tribulus or something. What do you like? Or like even maca root? Like a little bit of it. I mean even some of these, like Ashwakanda, Mighty Maca. Ashwagandha raises testosterone in women.

Dave Asprey (55:12)

So Ashwagandha is a tough one.

Dr. Sarah (55:14)

But it's like that's why women get so irritable on it is you have to cycle it because it's raising that testosterone just A little bit too much for them. So you can get them in a good place with the hormone therapy and then add on something that raises. You can always do like a testosterone cream. Yeah, this is always an option. That's why I tell women, if we can't get you there, get a cream, add it on, it's fine. I think just know that it might make your hair shed, but it's also

Dave Asprey (55:36)

like they'll notice if that happens and it's unlikely at lower doses. And I would recommend for all women, even if they're doing the vaginal progesterone first kind of direction that you've got. You should have some testosterone cream if you're in a relationship because it's really useful on date night. Just believe me on this.

Dr. Sarah (55:57)

We believe you. I think it's just this diversity in what you could do with hormones and you're just talking about just using it as an optimizer for a sex life. And this is amazing. This is how we should look at hormones.

Dave Asprey (56:11)

You want to look at them as foundational to your longevity strategy and to having a brain that works. And if you have those two things, you probably will want to have a sex life. So you should do all three. It seems to go in order for me. But the cognitive function, I don't think we talk about that enough. Because testosterone drives dopamine and dopamine makes you care about working on things that are important to you. It motivates you in men and women. So if you're just feeling, I can't be bothered to get out of bed, well, then maybe it's a testosterone dopamine access thing, or maybe it could just be a thyroid thing because low thyroid just makes you tired all the time. Even if you have libido, you're too tired to use it. So how many times do you find that you have to treat thyroid alongside sex hormones for longevity?

Dr. Sarah (56:56)

You do need to pay attention to the thyroid. It's like the other thyroid important access there for sure. I will say though that women tend to get treated with the thyroid and then over treated and then everybody ignores the sex hormones. It's kind of what's happening. So they'll do that first and they'll do that for years. You can't ignore the thyroid, but you can often. Like what we try is to optimize it with supplements like that one. Why don't we try that functional medicine approach with the thyroid where you truly can get that to bounce back. That is supposed to work your entire life, whereas ovaries we know aren't supposed to really work your entire life.

Dave Asprey (57:30)

I don't see any like 60, 70 year olds who have functioning thyroids.

Dr. Sarah (57:35)

But at least it'll get you kind of like a little bit further than your ovaries. Like fail at like 33.

Dave Asprey (57:40)

It's true. It lasts longer. There's also a recent study where they did autopsy analysis on cadavers and something like 80% of people over 70 had oxalate crystals in their thyroid glands which are disrupting functions in the reproductive system.

Dr. Sarah (57:56)

And I wonder where they get the oxalate from it.

Dave Asprey (57:58)

You're not getting it from steak, you know, sorry. Kale, spinach, raspberries, almonds. Like all the vegan superfoods just punch you in every organ you have, especially the glands. Yeah. Oh, it's terrible.

Dr. Sarah (58:11)

It's really funny. Iodine, you know too, we have a massive iodine deficiency. So that could also women. So there's more. For example, breast and uterus health. We have more iodine receptors than in the thyroid. And we function like. Doctors will tell women to stay away from the very things that will make them healthy, which is hormones and iodine.

Dave Asprey (58:36)

I'm really torn on iodine. So in my mid-20s, when my testosterone was lower than my mom, my thyroid levels were almost undetectable. I mean I was a wreck. And I just remember the lights coming back on. And then I had Hashimoto's. Probably still do have antibodies. They go away and come back sometimes, but they tell you, and there's actually good studies that say if you take iodine and you have Hashimoto's, it could get worse. So they tell you to stay away from iodine. What's your take on that?

Dr. Sarah (59:03)

So I think it's bullshit.

Dave Asprey (59:06)

Can I just high five you? Because you need iodine everywhere in your body. Avoiding it because you're. No, you just have to take it.

Dr. Sarah (59:12)

I think what. So I've been, you know, I've been doing this for a long time, like 10 years. And I really hear this all the time because one of our main recommendations is when women start hormone replacement therapy that they start iodine one because 90% of them have fibrocystic breast disease. They have density and cysts. And the only way that you can metabolize estrogen. Actually it's not. Again, it's not the liver. Your breasts and your uterus are getting rid of estrogen. So just you need the iodine to actually do that. So what happens is we're iodine deficient. It's not in our Diet, and then everybody gets. And actually it could be a precursor to breast cancer. So when they start iodine, what happens is it binds fluoride and bromide.

Dave Asprey (59:55)

They need to get out of there.

Dr. Sarah (59:56)

Yeah, they bind to the iodine receptor. And so when you start iodine, it pushes the bromide and the fluoride off. And these are extremely toxic. So like neurotoxic. They can cause flushing, headaches, fatigue, like a lot of really bad symptoms, which can be attributed to possibly thyroid symptoms. Where these studies, they show that if you take iodine, it makes your symptoms worse. It's giving your husband probably these massive.

Dave Asprey (60:19)

It makes the antibodies worse ones. I saw.

Dr. Sarah (60:22)

But I think maybe at first, but ultimately you need.

Dave Asprey (60:25)

Yeah, you can't avoid a critical mineral for the rest of your life because of that.

Dr. Sarah (60:30)

Yeah. So I think, well, you're gonna have to get the antibodies. Even if they spike at first, you're gonna have to get them down like another way.

Dave Asprey (60:38)

There's also some really intriguing research on massaging iodine into the breast, both for fibrosis and even for cancer. And that seems like a pretty mechanistically sound approach. But you can also get too much iodine. How does that work?

Dr. Sarah (60:56)

It's hard, but you can. I mean, I think people, they worry so much about getting too much that they're avoiding it and instead they need to worry about the deficiency. But you have to eat it a lot. Like over 50 grams, it's a lot, like half a teaspoon you have to be taking. And even then your body excretes it.

Dave Asprey (61:17)

There's a really easy way to tell when you've hit your iodine max. You get watery sinuses, not mucus. It's like water in your nose.

Dr. Sarah (61:28)

Interesting.

Dave Asprey (61:29)

And so that's a pretty clear thing. And the old test that I learned from 80 year old people who've been doing this for a long time in the longevity world was you get Lugol's iodine and it needs to be 5 or 10%. The 2% they sell on Amazon is bullshit. It's like water. It's stupid. So you put a drop on your arm right here, like the size of a dime, just one drop. And you rub it in and you let it sit there. If it's gone in less than 24 hours, your body is sucking it up because it needs it. And then, so that means, okay, treat it for a while. And I've done this for years. Then if you put on five or 10 drops and you put it on and then it sticks around for 24 hours. Good. You got your levels up where they needed to go. And if you put it on again the next day, runny nose. Right. So that's a way to. It's a quick and dirty old way to just tell what are you doing with your thyroid? And then the question is, do you want thyroid topically or do you want it orally? What do you like better orally?

Dr. Sarah (62:27)

Because the uterus needs it too, which I think you could put. We. For our patients. Estrogen also causes bleeding and we have side effects from that. So the iodine really helps with that. And you can put it topically, but we do get a better effect.

Dave Asprey (62:41)

Do you use Lugol's or Kelp?

Dr. Sarah (62:44)

Kelp, but we just. Hey, whatever.

Dave Asprey (62:46)

You'll take how many micrograms?

Dr. Sarah (62:47)

So in order to treat fibrocystic breast disease, you have to at least 2000 micrograms a day.

Dave Asprey (62:51)

That's a lot of kelp. Was it like 10 pills or something?

Dr. Sarah (62:54)

Yes. So like, the Lugols tends to be like the more favorable that 2% that you went to. That's actually kind of what we recommend. That's really funny that you said that, but I mean, that's. It feels like that they feel like they're not overdoing it. So we kind of hit that sweet spot where they feel safe about doing the iodine and then we back off after a while. So you only really need to do it once or twice a week after the pain goes. If you have no pain in your body, like in your breasts or uterus, then you don't. Then you have plenty of iodine. I think that's also like a marker that women know they have. I love this, like, a lot. But if their breasts are not full or painful, they have plenty of iodine. This is very easy for women to tell.

Dave Asprey (63:30)

And what if you were to get too much iodine? I actually don't know the long term negative effects of, like, it can.

Dr. Sarah (63:37)

Well, long term, I mean, you'd want to stop it, but it can kill bacteria, I think, is the biggest thing. So it can probably kill your gut bacteria and disrupt your microbiome, which would be.

Dave Asprey (63:45)

Kelp won't do that, but Lugols will.

Dr. Sarah (63:47)

That's probably like where the. And I think it can impact your. You'd start to see skin and nail changes and things like that, but you have to get like, pretty high.

Dave Asprey (63:55)

Okay. Yeah. Iodine's underappreciated. A lot of supplement companies, including me, were relatively cautious on it, mostly because of regulatory things like that. So I include it in minerals 101. So if you guys are on vitamin D and Minerals101, you're getting a moderate dose of iodine, because that's what I can put in there.

Dr. Sarah (64:12)

And that's okay for maintenance.

Dave Asprey (64:14)

Yeah.

Dr. Sarah (64:14)

Like, what I'm talking about here is a treatment, probably for this, but if. For maintenance, like, if you're fine and you just want to maintain, and you're

Dave Asprey (64:22)

probably not using moron's salt. Did I say that right? Which is iodized, but is also stripped of all of its other trace minerals,

Dr. Sarah (64:31)

and it tastes terrible.

Dave Asprey (64:32)

Yeah. So the chances of you getting iodized salt are very low. So you need to supplement iodine if you're using healthy salts, and if you're using unhealthy salts, you probably need to supplement potassium and a bunch of other minerals. So you kind of have to supplement either way. I feel like it's unfair that you've put all this attention on women's health and just ignoring men's health. And we don't have vaginas to treat our hormones. So now that you give me vagina envy, when you're working with men, what's the best way for men to get hormones? And do we need progesterone?

Dr. Sarah (65:04)

Yeah, I mean, men do need progesterone. I actually think they really love it. I find that also converts to testosterone in men. So you can raise testosterone levels in men with progesterone as well. Some of them feel better because they feel like if. Especially if somebody over converts a lot. Right. Like, so if you think about it, you're starting higher up at the pathway. Like if you have a really heavy DHT converter.

Dave Asprey (65:25)

Right.

Dr. Sarah (65:26)

You can start higher up and they may convert less and they might feel more calm and stable. Because sometimes with those injections, you know, you're doing them twice a week. And I hear from men that you can get swinging and like a little bit of.

Dave Asprey (65:37)

We all want swinging.

Dr. Sarah (65:38)

High and a low. Who's obsessed with.

Dave Asprey (65:44)

Sorry, keep going.

Dr. Sarah (65:46)

So this, I think, maybe provide some more stability. So you could. Sometimes you could do the testosterone with progesterone, and you can also lower that testosterone dose because you're giving them progesterone. Injected progesterone, oral, you know, because again, you're wanting to force that testosterone. The problem with women is giving them the oral. It's a sleeping pill, and it can raise their testosterone too much.

Dave Asprey (66:06)

It can make men tired too. It's kind of good for sleep. I mean, should we be like perineal Boofing it. Like, how does that work for men? For progesterone?

Dr. Sarah (66:15)

Yeah, no, but I mean, like a 200 milligram is 100 milligram.

Dave Asprey (66:20)

That's quite a lot for a guy.

Dr. Sarah (66:22)

But you'll have to back off your testosterone to do that.

Dave Asprey (66:24)

Okay. And you would do that orally?

Dr. Sarah (66:26)

Yeah.

Dave Asprey (66:27)

What about suppositories?

Dr. Sarah (66:29)

I mean, I don't think they're like anybody, any either sex loves them as much.

Dave Asprey (66:33)

Nobody loves them. But we don't have vaginas over here. I mean, come on.

Dr. Sarah (66:35)

Yeah, it would work really well.

Dave Asprey (66:36)

Okay. So for guys who are really sick, that might be a thing, but I'm not going to do that either.

Dr. Sarah (66:40)

Yeah, because especially when there's like an oral option and you don't need that much, it's kind of like the. You're not trying to get, like for women. If you look at the units, like for women need again, 30 times the amount of progesterone. They really need a lot. So we like, a little bit of a pill is not going to work for us, but a pill, like a tiny pill would work for men.

Dave Asprey (66:59)

I had a guy on maybe 800 episodes ago, and he was an older doctor in the functional medicine world. And maybe his name will come to me. I have a pretty good memory. But that's a lot of shows. And it was really funny the entire episode. No matter what the health problems. Progesterone, progesterone, sore neck, Rub it on your sore neck. And he actually kind of had a point that we went through some of the biochemistry and said, yeah, it works for men too. So progesterone, it's kind of an interesting thing and I don't think most men are aware of it, but if you can't sleep at night, you could try some before bed. Right.

Dr. Sarah (67:30)

I think it's part of that optimizing thing for men that you. You make sure they're testosterone. You know, you're getting them, you're looking at the different pathways of metabolism and you can definitely utilize progesterone for them. Just like. Yeah, yeah.

Dave Asprey (67:42)

What about wild yam cream?

Dr. Sarah (67:44)

No, it's so yam. It's. First of all, it's garb. Complete bullshit. I've said this so many times, but it's like yam, you. You have to have the little enzyme to convert the yam to progesterone, first of all, which I don't think anybody really has.

Dave Asprey (67:56)

Well, you can, but there's really good science out. It takes nine steps in a chemistry lab to Turn yams into progesterone and some probably vegan, no offense, vegans. It was like, oh, if wild yams confirm that, maybe we should just take wild yam extract and then magically our hormones will change. No, it doesn't work like that. You're not a chemistry lab. So, yeah, wild yams won't do anything but make you feel superior and empty your checking account.

Dr. Sarah (68:22)

Yeah, okay. You can eat them if you want. Arselides, though, I mean, if people need. The skin is a barrier. It's meant to keep things out. So you're trying to. If anytime you try to put something on the skin to try to get it into the body, unless it's a small molecule like iodine, you're not going to get more than 30% of these massive hormones to get through anyway, like yams. Like, it's probably not even doing, not even getting into the body for you to convert it.

Dave Asprey (68:44)

I think sticking yams in your body anywhere other than your mouth is probably a bad idea.

Dr. Sarah (68:48)

And even in your mouth.

Dave Asprey (68:49)

I actually would agree. Yams, unfortunately, are high in oxalate and it's not a good choice. Eat white rice. I'm pretty much Asian at this point.

Dr. Sarah (68:59)

Good. Eat it forever. White rice and beef. So you're good.

Dave Asprey (69:03)

That's kind of my diet. I mean, I eat a bunch of other stuff too, but.

Dr. Sarah (69:06)

Yeah.

Dave Asprey (69:09)

Can we talk about oxalates and hormones?

Dr. Sarah (69:11)

Sure.

Dave Asprey (69:12)

Are you into that?

Dr. Sarah (69:13)

Sure.

Dave Asprey (69:13)

Okay, tell me about oxalates.

Dr. Sarah (69:15)

Well, I know they gave me some kidney stones.

Dave Asprey (69:19)

Oh yeah? Yeah. So you love oxalates.

Dr. Sarah (69:21)

I mean, it took me a while to figure that out, but I was into like matcha tea, I think.

Dave Asprey (69:26)

Tell me. Okay, let's define oxalates for people who haven't heard me. I just said a low ox challenge. So oxalates are plant protective compounds. When you eat the parts of the plants they don't want you to eat, they form razor sharp calcium crystals that accumulate in your ovaries, in your brain, in your uterus, in your breasts, in your joints, anywhere you've had an injury, and in your kidneys, where 70% of kidney stones are caused by oxalates. Okay, now tell me about your matcha.

Dr. Sarah (69:52)

And they call it a stone. And you think it's going to be like really smooth like a river stone. And it's actually shaped like the death star.

Dave Asprey (69:57)

It's like a piece of coral coming out.

Dr. Sarah (69:59)

Yeah, yeah. So I mean, I was doing the matcha for a long time because one, the compounds in it are directly toxic to ovarian. Cancer cells and cancer cells and just those overall benefits which now you take a pill. Exactly.

Dave Asprey (70:14)

Taken it for many years. It's a really good longevity compound.

Dr. Sarah (70:17)

So I just switched to that instead of drinking the matcha tea, but I would do collagen and matcha tea. And I did that for a long time and then just got a bunch of kidney stones and lit up the CT scanner with kidney scones. Haven't had one since, though. Since I stopped, that was the only green thing I was really eating. And once I stopped it, I had no problems.

Dave Asprey (70:35)

It's really interesting because I'm the world's biggest collagen fan. And excessive collagen converts to oxalate in the body as well.

Dr. Sarah (70:42)

Interesting, right?

Dave Asprey (70:44)

And so this is because proline, one of the amino acids in it, and even glycine will convert via the glyoxylate pathway into oxalate. So you can give yourself kidney stones metabolically with toxic mold, with Candida and with eating certain amino acids in excess.

Dr. Sarah (71:01)

I love glycine, I take it.

Dave Asprey (71:03)

Well, there's the rest of your kidney stones, so you might need to cut down to like 3 grams a day or increase your lemon juice intake so that you have more citric acid to dissolve them. But a lot of women do this. They're like, oh, I'm drinking moldy coffee. So I have a stress response to coffee. So I went off of that and I went on matcha. And I love a good matcha and I don't mind like a little one every now and then, but matcha's a very high dose of oxalate. And right now there's people giving me comments like screaming, ah, that's not real. Actually, it is. So you can handle 200 milligrams a day.

Dr. Sarah (71:36)

I lived it.

Dave Asprey (71:37)

Yeah, I did too. You can have 200 milligrams a day for the average metabolism. And if you eat the superfood diet with matcha and unfortunately dark chocolate and raspberries and even sweet potatoes, which I've been a fan of, and most nuts, but not all, and spinach and kale and all beets and a lot of these things that you're like, what? Yeah. Eat a bunch of that stuff, especially juiced, and it goes in. You can get a gram a day, five times more than your body can handle. And then you say, but I feel great. Yeah. Because it builds up over time in your tissues and you're probably having gut issues that you don't recognize are caused by razor sharp calcium crystals in your gut, disrupting things. And you get chronic UTIs, not because of bacteria, because you have little glass shards slicing your urethra where the bacteria get in. So you take the oxide out of the diet and magically the symptoms go away and you don't have interstitial cystitis anymore. And it goes on and on. So matcha. Love it. Ceremonial grade matcha. Have it once a week. Like, get a cool bowl in the whisk. I love that. And I'm into it. I have matcha at home. But if you make a matcha smoothie every day and just add some cinnamon, which is high oxalate as well, and just watch what happens, and you're like, why do my muscles hurt? Because there's little sharp things in them. That's why they hurt.

Dr. Sarah (72:54)

And it's interesting how the kidney stones always precede the heart disease or something that oxalates.

Dave Asprey (72:58)

They do. Yeah. It's much bigger than you think. And for fertility, the amount of oxalate you can have in your ovaries and in your uterus, it's there, especially in vegans.

Dr. Sarah (73:08)

I didn't realize it was in the. It makes sense that it would deposit in places, though.

Dave Asprey (73:12)

Yeah. And so I just think this is one of those mistakes we've made and say, eat the whole grains. Whole wheat has something like 40 milligrams in a normal dose. White flour has two milligrams. Coffee has two milligrams. Right. So that's nothing. So if you're going to eat wheat, which in the osis especially is a really bad idea, eat white flour. Like, throw away the whole wheat. It is literally. They only fed it to the peasants because they didn't care if they died.

Dr. Sarah (73:40)

White flour tastes better anyway. Like, if you're going to do it, why not just, yeah, eat, of course not.

Dave Asprey (73:43)

Or whatever? I can't really say that. I have a question. Do you believe in democracy? No, man, you're too smart for my joke. So normally people say yes, even though you should question democracy at this point, at least the way they've implemented it. But there's more people who say croissant than say croissant. So by the power of democracy, French people have to start saying it the American way. So if you're in France right now, number one, I apologize. But number two, you're going to have to question your belief in democracy or say it the dumb American way so you get straight.

Dr. Sarah (74:23)

It makes perfect sense.

Dave Asprey (74:24)

And this is really just an argument for white flour. And yes, when I go to France, I treat my Gluten deficiency disorder. Like I can eat European wheat, different species, no glyphosate. It tastes amazing, take enzymes and it actually works. And I'm pretty darn sensitive to it, so. Okay.

Dr. Sarah (74:41)

But I mean, it shows, though, that you're resilient. I mean, if you're able to like take a challenge like that, though, a temporary one, and do fine, like you've. I feel like we were winning. Like if you, if you're sensitive to it and you can tolerate it.

Dave Asprey (74:52)

As a 300 pound guy who really couldn't tolerate anything for a long time, to be able to do what I do now, I'm so incredibly grateful. But the biohacking thing kind of works. Yeah.

Dr. Sarah (75:03)

I mean, it shows that it works.

Dave Asprey (75:05)

Yeah. And it's like, if I can do it, I'm the worst case. So if you're listening to this, it's probably going to be a lot easier for you to build resilience and hormones at the center of it alongside mitochondria who are actually at the more center of it. Dr. Sarah, it's been a pleasure having you on the show. Where can people find out more about your work and the things you make for hormones?

Dr. Sarah (75:27)

I'm online in 50 states, so at www.innerbalance.com we treat only women, but we treat them in all 50 states.

Dave Asprey (75:37)

If I wanted to get treated and I just called up and said I identified, would you treat me?

Dr. Sarah (75:41)

You. Yes. It feels. No. Just because. I'm just kidding.

Dave Asprey (75:47)

Put this in your vagina. What? Ah, this is so hard.

Dr. Sarah (75:50)

It's not gonna work.

Dave Asprey (75:52)

Okay, well, I appreciate you taking care of women. It is true that men and women have different, just different needs, but it's the same ingredients. We just mix them differently. And, and I just want to say 58% of biohackers have been women from the start. It's always been about humans. And you go to the biohacking conference and it's an even mix because everybody just, they want to feel good all the time. Right. And I think it's much more personalized than just man versus woman, or old versus young, or different races and things like that. It's very personalized. And if you get the big things right, like hormones, it unlocks just a level of power where then you can do the little things because they don't feel like work anymore.

Dr. Sarah (76:38)

Exactly.

Dave Asprey (76:39)

You're helping a lot of people. And thank you.

Dr. Sarah (76:40)

Thank you. Thanks for having me. Yeah. Thank you for you for doing what you do. Thank you for you.

Dave Asprey (76:46)

You're very welcome.

Sponsor/Ad Voice (Joy Mode, Qualia NAD, Ignaton) (76:49)

See you next time on the Human Upgrade Podcast.

Podcast Disclaimer Narrator (76:58)

The Human Upgrade, formerly Bulletproof Radio, was created and is hosted by Dave Asprey. The information contained in this podcast is provided for informational purposes only and is not intended for the purposes of diagnosing, treating, curing, or preventing any disease. Before using any products referenced on the podcast, consult with your healthcare provider carefully read all labels and heed all directions and cautions that accompany the products. Information found or received through the podcast should not be used in place of a consultation or advice from a healthcare provider. If you suspect you have a medical problem or should you have any healthcare questions, please promptly call or see your healthcare provider. This podcast, including Dave Asprey and the producers, disclaim responsibility for any possible adverse effects from the use of information contained herein. Opinions of guests are their own and this podcast does not endorse or accept responsibility for statements made by guests. This podcast does not make any representations or warranties about guest qualifications or credibility. This podcast may contain paid endorsements and advertisements for products or services. Individuals on this podcast may have a direct or indirect financial interest in products or services referred to hearing. This podcast is owned by Bulletproof Media.