← You Are Not Broken
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- [00:04]
A
Welcome to youo Are Not Broken, the podcast that challenges everything we've been taught about midlife, hormones and sexuality. I'm Dr. Kelly Casperson, board certified urologist, author, and a leading voice in women's sexual and hormone health. Enjoy the show.
- [00:17]
B
Hey, everybody. Welcome back to the you're Not Broken podcast. Today I have my friend on Cynthia Thurlow, and we've just been chatting and not hitting record. So now we're going to hit record and talk about the gut. Although other things might come up, such as the perils of book tours, the sexless lives of menopausal women, and what we all want to do about it. So welcome to the youe're Not Broken podcast.
- [00:37]
C
Oh, so good to be here, Kelly. And as listeners should know, we probably spent 15 minutes unpacking the lives of what happens during a book tour.
- [00:45]
B
They're like, wait, the podcast just started. She didn't hit record. You're in the middle of book tour for the menopause gut. Balance your microbiome, Reclaim youn Health in Midlife and Beyond. The gut's very hot right now. This couldn't be more timely. I think five years ago there would have been crickets for this book. And now it's hot, hot, hot. Can you give us your overview of, like, it's time to write a book about this? Cause it's getting buzzworthy.
- [01:09]
C
Yeah. You know, it's interesting. This is obviously content neither you nor I learned about during our medical training because it's really been the last five to ten years that all this proliferative amount of research has come out. What I think is really interesting, and obviously having a podcast myself, and I'm interviewing scientists and other physician colle, other experts. I was like, gosh, there's a lot of conversation about genitourinary symptoms and heart health and bone health and brain health. And yet I think really at the crux of all of it is this gut connection that most of us are probably not making the connections with because traditional allopathic medicine is very siloed. And that is just the way the curriculum is taught. But as I started to interview more experts and I started working with more women over the past 10 years, I was like, why am I seeing so many changes in the microbiome? Why is stool testing pretty consistent? Why are there consistent patterns of symptoms? And how does this all interplay with the gut? Like really thinking about the gut as a gut, bone axis, gut, brain axis, gut, genitourinary access and how nothing exists in a silo, but really Thinking about the microbiome as this main communication point, an inflection point for women in midlife. Like I'll make the argument that although it's super important that we're taught, we talk about lifestyle, we talk about replenishing hormones, we talk about targeted supplementation. Another part of the conversation really needs to be what are the things that are changing in the gut that are exacerbating symptoms and how do we address it? We don't yet have a primary indication for hormone replacement therapy for restoration of the microbiome. But, but looking at the research, I do think that is the direction things will go in. Like we will get an indication at some point because if we look at the research on women looking at younger microbiomes, gut microbiomes versus menopausal microbiomes, restoration of estradiol, progesterone therapies, you can get a younger looking in air quotes, microbiome composition that looks much more like a younger woman. So as we are losing hormones, it is so much more than just about bone, brain, heart health, genitourinary symptoms. There's a whole other world out there that we're not focused on. But I think it's another layer to supporting middle aged women.
- [03:27]
B
I love that the WHI and my listeners are pretty savvy, but I always want to kind of start at the beginning for some people, but. So the WHI was heralded as this really horrible thing, but there was actually a lot of good that came out of that study because it was massive and it was randomized, placebo controlled. But in the people who took hormones, they had an approximate, correct me if I'm wrong, 30% decreased risk of colon cancer compared to placebo. And this was not the first time this was signaled. If you actually go back before the whi, there's also studies that show decreased risk of colon cancer compared to people who don't take hormones. And the theory being microbiome, gut's more able to heal itself, fix itself, find mistakes. And kind of a way to wake people up is like when you're postmenopausal, you have the gut microbiome of a man, men have more colon cancer than women do. And not to say it's bad, just to say it's different. And estrogen's protective, just like estrogen's protective, like you said, bone, brain, immune system, all of that stuff. And I think, you know, when you look at the amount of colon cancer in the world, it's a top cancer, it's very common, Nobody ever talks about what they should do to prevent it, except for get your colonoscopies, which we should, we should all get our colonoscopies. But I think, you know, it's crazy that if there was a drug that we invented right now that decreased your risk of colon cancer by 30%, it would have a Super bowl ad that is a massive cancer reduction and nobody's talking about it.
- [04:57]
C
And it's so important because we're starting to see escalating rates of younger patients with colorectal cancer. And so I keep asking gastroenterologists that are on the podcast, what do you think are some of the reasonings behind this? And pretty consistently they are saying, you know, there's environmental, you know, the ultra processed foods and a lack of fiber in the diet. And so I really think that colonoscopy is both diagnostic and screening at the same time. And so there's a great deal of value to this. But when we start thinking about the threshold of, and the implications of that loss of hormones, I think it is probably lack of fiber, ultra processed foods, environmental. And then I start thinking about, like, what's happening to the immune system as we're aging. What's, what is happening with this baseline low level inflammation that is at the basis for nearly every chronic disease state that we start seeing escalating in mid age and beyond. And I think for a lot of women, especially the women that say to me, you know, very persuasively, they're like, listen, I'm in perimenopause, I'm in menopause, I feel good. Menopause is a natural state. If I'm not having symptoms, why would I start hrt? It's helping them understand, like, you may not be particularly symptomatic, but smoldering beneath the surface is so much inflammaging and inflammation that it is staggering. So maybe at 45, 50, 55, you don't feel bad, but what are things going to be like when I hate this term, when I did my training years ago, the senile vagina, but the osteoporosis, the cardiovascular disease, the neurocognitive decline. And, and then you think about the implications of a senile microbiome and all of these sequelae from these things. It's like, let's start educating women at a younger age. They know that it's like, it's not a question of if, but when it will happen. Menopause is a natural reflection point in the trajectory of our lives, if we live long enough. But it isn't optimal. Like it's not optimal to live without hormones.
- [07:03]
B
And living to age 86 with 40 years without hormones actually is not natural on a societal level. There are always outliers. Just like Bill Gates became a billionaire without going to college, there are outliers. But most people who didn't go to college aren't billionaires. Right. And so like this is very timely for me right now because my mother in law broke her hip last week. Uh, oh yeah. And I'm the only medical person in my family. And so I'm on the couch like screaming dumpster fire to myself because otherwise I sound like a crazy person in the world of like the non medical people. Like they're fine, everything's fine, she's fine. And in my head I'm like, I'm like not fine, not fine. Tripping on a curb and your hip cracking is not natural. There's nothing natural about going down 5 inches of an incline and your hip cracking. Right? And so like I don't, when you were saying, you know, people are like it's natural, blah blah blah. I'm like, just because you feel good right now doesn't mean that's the optimal way for the world to be. And number two is like decline is slow, chronic and progressive. It's not all or nothing until the hip fracture Tuesday, right Until the colon cancer day, until the blah blah blah. And we're, none of us are getting out of here alive. Like I get it, like, but let's try to be as healthy and resilient as we can. And I think we all want to be resilient. And when you think of hormones as a resilience tool, it starts making sense.
- [08:35]
C
Yeah, well, and I think about the fact that younger generations are being educated. I think about how my 18 and 20 year old sons know what HRT is. They know what it is. They understand that women take this in perimenopause and menopause. They understand andropause because my husband and I talk about these things. So like younger generations are going to have a sense of what to expect. Whereas I think the boomer generation, which are my parents, there was so much shame and secrecy about aging. Like my mother told me she was 30 years old until she, until I was 30.
- [09:08]
B
No, she did, she did it.
- [09:10]
C
Yeah. And I was like, mom, you think maybe like we acknowledge this is actually probably a little silly. Like I mean no one thinks that you are 30 years old. And obviously if I'm 30 at some point you're going to hit your 50s. But my mom's generation never talked about their menopause experience. My grandmother's generation never talked about their menopausal experience. So like, our generation is really learning a new way to navigate education and awareness and decreasing shame and secrecy, which is what I love so much about. Your platform is helping women find conversations to talk about which should not be sensitive subjects but can be for many. It's like, let's talk about this so that people are aware of what options are available. And to your point, about your mother in law, my mother in law three years ago fell and broke her hip and then two years ago fell and broke her femur on the same leg. And so she has not been fully ambulatory without a walker in two years.
- [10:14]
B
Dude, like I'm completely deviating from the gut. We need to go back. But on the topic of mother in law's breaking hips, because people need to know this, There is a JAMA paper published. It's the STEP High study published in 2025. They did a follow up paper that they just published looking at average age 73, hip fracture, frail older women, testosterone versus placebo.
- [10:37]
A
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- [11:29]
B
testosterone was adjusted to have a lab value between 100 and 150.
- [11:36]
C
Ooh.
- [11:36]
B
People would say that's on the higher end, right? So we're talking 5 milligrams, we're talking 10 milligrams. But adjusted to get them into the 100s. That's very important in and of itself. And so they published it as a negative study, meaning their endpoint was distance. Walked in a six minute walk test six months after you broke your hip? Well, testosterone doesn't make me fast. It doesn't make you fast. Testosterone doesn't make people fast. Right. So but in the study women on testosterone at six months after a frailty fracture, 50% decreased risk of needing a cane or walker.
- [12:10]
C
That's amazing.
- [12:11]
B
Which is independently associated with living independently and mortality. Cane or walker after hip fracture is an association with mortality.
- [12:20]
C
Yeah, that's significant.
- [12:22]
B
Ergo. So I literally, my, my mother in law is in the hospital and I send her the step high study and I'm like, please get discharged with some testosterone. They're going to think it's crazy. Just tell them that your daughter in law is like the premier testosterone female expert in the nation. And I'm sorry, and I'm sorry, but I'm like if your mother in law has a 50% decreased risk of needing a cane or a walker at six months and the medication is safe and effective and cheap, it seems like a no brainer.
- [12:51]
C
Well, it just reaffirms for me why I feel better personally with a higher free testosterone level. Like my integrative doc and I have these ongoing vibrant discussions and he's like, but you're a little bit on the high side for free testosterone. I said, but I feel better. Like I symptomatic, like I think about sex, like whereas when it's lower I'm like, you know, I don't think about sex.
- [13:14]
B
If you, if you look at most of the testosterone studies and even in the sexual health ones, these people weren't walking around with testosterone of 40, they were walking around with testosterone of 120.
- [13:25]
C
I think we need to have like these conversations are vital because we still have clinicians that are prescribing so conservatively. Just based off of this is where the reference range should be.
- [13:36]
B
Reference range on Quest labs is based off of two papers that are ancient. And to me I'm like, I know all of this so much. Like I can, I can dispute all of it. So Susan Davis came out with a paper, 2025 that did about 1800 Australian women normals, right. And converted to American values. Once you're at a testosterone of eight, you're in the lowest 10%. Well, our normal values go down to two for Quest Labs. So you can be in the lowest 5 percentile and be considered normal.
- [14:08]
C
Normal's not optimal.
- [14:09]
B
Normal's not optimal. Okay, let's talk about the gut. When I was in medical school, we hadn't yet discovered that H. Pylori caused stomach ulcers. Bugs were bad, we killed them all. And now we think, you know, fast forward, not that, like, I'm not 30, but I'm not that old. Antibiotic use in children is linked with like, not great long term outcomes. And they think it's because of your microbiome gets messed up. And like, I saw this T shirt. I don't own this T shirt. I want this T shirt. You should get this T shirt for your book tour. And it says, my microbiome made me do it.
- [14:48]
C
I love that. Yeah, I need to go find that T shirt.
- [14:51]
B
You just get one made. It'll be good for the stage. But like, the microbiome is more numerous than cells in our body because bacteria are smaller cells than human cells. When people are like, how's that possible? Makes serotonin, makes dopamine, makes likely things that help strengthen our bones. Bones have serotonin receptors on them, like, incredibly important. And then we just dump poison on them all day long.
- [15:17]
C
Well, think about, like when we are born, depending whether or not we are a vaginal delivery or C section, whether we are breastfed or formula fed, it's setting up the microbiome constituency. And we know there's like three key kind of deviations. Obviously puberty, not surprisingly, pregnancy, if we choose to become pregnant, and then perimenopause. And you started the conversation talking about how women in menopause, our microbiome starts to resemble a male's, but that's not actually to our advantage. And so part of the conversation is what are the inputs that dynamically impact the microbiome? And I think about alcohol, I think about antibiotic use, I think about proton pump inhibitors, I think about chronic stress. And you and I were just talking about stress. But even adverse book tours. Book tours, we'll just keep saying book tours. Like I told my husband two weeks ago, I was like, I woke up one morning and I was like, I must have hit a wall because I'm so tired. And he said, I'm glad you're human.
- [16:12]
B
Oh, dude, I just. In the last, like very short periods of minutes, you are married to an incredibly insightful human.
- [16:20]
C
I'm really, and I don't say this lightly, one of the best decisions I ever made was marrying Todd, like, full stop. I remember my grandmother telling me when I was 18, when you think you're 18 and your grandparents and your parents know nothing, she said, one of the most important decisions you will ever make. And she was very much a free thinking feminist woman. One of the most important decisions you will ever make is who you choose to marry, full stop. And so I always say a lot of things have gone wrong in my life. But one of the things that went really, really right was when I met him and how great a human being he is. And just so he's like my biggest cheerleader. Like, the happiest, most positive human being you've ever met. And he's super smart, which I always say, like, he's smarter than I am, which is a good thing.
- [17:07]
B
Right. It's so unfortunate sometimes, but it's actually a good thing.
- [17:11]
C
Yeah. I'm like, I think now one of my family, like, marry someone smarter than yourself. And I was like, I didn't understand that. But now I'm like, yeah, yeah, absolutely. Mar someone smarter than yourself. Yeah, that's good things for you, I think.
- [17:22]
B
Definitely marry somebody who's, like, better at tech.
- [17:25]
C
Oh, the engineer. I mean, it's like, just the way his brain thinks.
- [17:29]
B
I vote for the engineer as well.
- [17:31]
C
Yeah, no, I'm married to an engineer. Oldest son is in engineering school. And I'm like, so smart and just the way they think. Very logical, rational, calm, cool, collected, and both socially adept. So there's that other side of it
- [17:45]
B
that's a nice combo. You don't always get that.
- [17:46]
C
No.
- [17:47]
B
Let's talk about how mouthwash is bad for our microbiome.
- [17:50]
C
Oh, it destroys your nitric oxide production. And so, like, how many people, like, my father used Listerine every day of his life till he was no longer alive?
- [18:01]
B
That's what you were supposed to do. And I think I feel like the dentist didn't. I have lots of dentist listeners, and I love you, but I don't feel like they were like, okay, and now we're not going to do that anymore. Like, it's kind of like mouthwash is like the vaginal douche of the mouth.
- [18:19]
C
Well, anything that you put in your mouth, like chewing gum, like, my.
- [18:23]
B
Wait, what's chewing gum do?
- [18:24]
C
It can change the PH of your mouth. Not in a good way. Yeah, so, like, I was a prodigious gum chewer. So I was never a coffee drinker. And this is like, probably tmi, but for years, I rounded in cardiology service. I would go into patients rooms in hospitals. You have unusual smells. And my, like, go to was spearmint gum. I would chew gum, and little did I know, I was eroding the ph level of my mouth. And so now I think very thoughtfully about everything I stick in my mouth. And, you know, is it contributing to or is it making sure that the beneficial bacteria in my mouth are impacted in a negative way? Because we know the oral microbiome, vaginal microbiome, gut microbiome, et cetera, et cetera are all interrelated. And so you think about cumulatively over time. So now I just don't even chew gum anymore. I'm just like, no, thanks.
- [19:13]
B
I can't even imagine what vaping and smoking does.
- [19:15]
C
Anything that's cutting. I mean, you're cutting off oxygen supply.
- [19:18]
B
Cheese.
- [19:20]
C
Yeah.
- [19:20]
B
Really bad nitric oxide, just for people who don't know, it's good for heart health. It's also good for erections. And women get erections. Don't think you don't.
- [19:28]
C
And actually you have nitric oxide signaling in the gut. So it actually helps with gut motility. So I remind people all the time that when women say to me, I feel like my food sits in my stomach, and if they're licensed medical professionals, the next cause of concern is like, oh, my God, do I have gastroparesis? Which is this can be a side effect of long term poor metabolic health, diabetes. And I'm like, no, it's probably. You've got changes in smooth muscle contractility, with changes in progesterone and with declining estrogen, you very likely have alterations in nitric oxide signaling, which means things don't move quite as effectively. So it's not in your head. It is a byproduct of these hormonal shifts in the digestive system. So it's like, add it to the list of things that we need to consider for hrt. It's like, let's move stuff through our digestive system so that we feel like we're not bloated and constipated.
- [20:18]
B
Totally. Fiber is the new protein.
- [20:20]
C
Yes, it is. It's the new F word. Because depending on who my podcast host is, I've had some say to me, I would love to have you as a guest, but we can't talk about fiber. And I was like, why is that?
- [20:31]
B
Oh, it's like a religion.
- [20:32]
C
Fiber is not necessary. And I was like, well, if you understood what was happening at a cellular level with this concurrent decline in hormones, you would understand why fiber becomes more important, largely because of this alteration in short chain fatty acids. So these signaling molecules that are produced when we eat fiber, so we eat fiber, goes through our digestive system, it gets fermented, and out of that come these short chain fatty acids and why they're important. They reduce inflammation, they help with insulin sensitivity, they're helping with mucus lining, they're helping with communication of the brain. Like butyrate crosses the Blood brain barrier. And so as hormones are declining, we have less short chain fatty acids. And this is one of many things that gets tripped off. So adding more fiber into your diet is actually beneficial. But the carnivores like to argue with me. I'm like, I'm not saying that you can't do a therapeutic carnivore diet for a month or two, but like long term your body is meant to be omnivorous. Truly.
- [21:27]
B
It's kind of like the same argument that you don't need hormones after menopause. It's like true. It just might not be optimal. The medical population gets this. We've done a bad job of translating it to the lay population in, in my analysis because people will be like, how do I know I need it? And it's like in the medical world you only need something if you're like going to die in an hour, right? Like they need norepinephrine, they need oxygen, they need two units of pack red blood cells, right? Like that's what need means to like the. And to the lay people they're like, tell me yes or no, is this a yes or no? And so I think the word need, I don't know, I've just been paying attention to this because you see it a lot with testosterone. How do I know I need testosterone? And I'm like, well technically nobody needs, you can castrate a man, right? Like nobody needs it in the life threatening sort of thing. But man, it's an ad.
- [22:22]
A
If your face needs a moisturizer, your vulvovaginal skin probably does too. And for that I recommend Via Vaginal moisturizer from Solve Wellness. I'm a huge advocate for vaginal estrogen and Veea is the perfect complement. It's a non hormonal hyaluronic acid based moisturizer that replenishes moisture while soothing and conditioning dry vaginal tissue. It can be used alongside vaginal estrogen on off days or daily. For those who prefer not to use vaginal estrogen during menopause, lower estrogen levels can thin and dry skin everywhere, including vaginal and vulvar tissue, leading to irritation, pain with sex and even urinary tract infections. That's why maintaining healthy and hydrated vaginal tissue is important. For more information on Via by Solve Wellness, visit viaforher.com that's viathenumber4her.com where new customers get 20% off their first purchase this Women's Health Month use code DRKELLY5. That's D R K E L L Y5 for an extra $5 off. If you are a clinician, you can visit hcp.solvewellness.com for patient education materials and samples.
- [23:33]
C
Yeah, well, and it's interesting because a lot of my patients, they may not get the brain fog up front, they may not see alterations and lipids up front, they may not see changes in bone. But for them, especially for my thinner patients, they'll say, my vagina doesn't feel the same. Like, I'm getting recurrent UTIs or sex is just so painful, I don't even want to have sex anymore. And then they're like, okay, well, how do I fix that? I'm like, well, it's not to just keep prescribing antibiotics. It's actually something fairly simple. Ask me how many of my cardiology patients were on chronic low dose antibiotics. Like, it was a running joke between that and the benzos like Ambien, Ativan, Valium of a certain age group. But I think for many women that's like the first sign that there's probably something changing hormonally enough that it is compromising their quality of life. They may not even think about the other things yet.
- [24:29]
B
I'm seeing this a lot with GLP1s because the media is loving this with the GLP, the GLP1 vulva and vagina. And I'm like, if you're losing, first of all, if you're starving, because there are, there's some starving happening. If you're starving, all systems are like triage. Yeah, right. Pelvis, cut it off. Right. Like batten down the hatches, right? So first of all, starving. But second of all, if we're losing body fat, body fat does create an inflammatory, crappy estrogen product. Not the estradiol, right. But they are becoming more hypogonadal. You need vaginal estrogen, you need vaginal dhea, you need all of that. And so like, but to blame the GLP1 as, like, it's a medication side effect, that means you're not actually understanding the pathophysiology of why this is happening.
- [25:19]
C
Well, there's so much fear mongering that goes on. It's like whatever the clickbait is, it's whatever the most fear mongering statement can be. And then it just frightens people into potentially not getting the help they need. You know, someone was Talking about the GLP1 vagina and how now people are looking to get vaginoplasties because things are changing. And I was like, you know, let me Tell you something, I've had two C sections. That's as much attention as I want to that part of my body. But if a woman is deciding on her own that this is something she's pursuing, great. But to somehow suggest that women now need to have a vaginal overhaul because they've lost.
- [26:00]
B
Predatory.
- [26:01]
C
Correct.
- [26:01]
B
To me, I'm like, listen, a lot of people look at your face, and I could argue you make money off of your face. I think your face is distinctly different from your pelvic structures, which maybe 1, 2, 3. However many partners you have might be looking at it. And I guarantee you, they're just happy to be in the room with you.
- [26:21]
C
Yes.
- [26:22]
B
Right. So to me, I'm like. I'm like, you're gonna take $10,000 to re haul something that, like, are you making money off of this? Some people are, but most people aren't, right? So to me, I'm like, you're gonna do $8,000, $10,000 to revamp a vagina that you. I'm sorry. You don't even know what's normal in the first place. Where can you find normal on the Internet?
- [26:44]
C
I think it's as bio. Individual as we are as individuals. Like, I was getting a facial one day, and this lovely anesthetician, emphasizing she's an esthetician, she mentions to me she also does vaginal laser therapy. And so, out of curiosity, I started asking her questions, and I was like, talk to me about your training, and talk to me about women that come in to see you and what they're doing.
- [27:05]
B
And does she know who you are? No. Okay. You're like a secret shopper.
- [27:09]
C
Yeah. No, I literally was, like, asking all these questions. I was like, this is fascinating. I went home and had a whole conversation with my husband, and he said, I know how you think about things, like, laser on your face. I'm going to a licensed medical professional. No questions. But how many women are getting a facial? And then very innocently, they're told that there's a vaginal rejuvenation laser that this an esthetician can use legally. And I was like, hot laser in a sensitive body part. I think that's a hard. No.
- [27:39]
B
There's a very limited role for it that is only good when combined with vaginal estrogen or hormones. You can burn people, especially if they have very pronounced atrophy. I see all the people who spent the $8,000. It didn't help my sexual desire. Well, no shit it didn't help your sexual desire. It's not supposed to help your sexual desire. It's not what it's designed for. It's a laser. Right. So they go in thinking it'll fix a problem that it was never designed for and you're out a ton of money. So I think it's predatory in a lot of hands.
- [28:13]
C
Yeah. I mean, and I think it's, it's part of a larger conversation because I think as women are aging, I think even the most confident, well adjusted human beings, like the aging process can just be a little overwhelming depending on the day. And to your point about predatory practices, a woman's assuming if she's going to someone who utilizes these strategies that they are looking out for her best interest. Like really the way that that should be discussed should be like fully informed consent. Like what are you looking to have improve and can this modality help? If it could, great. If you have a problem that really is at a cellular level, a loss of hormones that drives ph changes, that sends epithelial line chains. So it just becomes a bigger conversation. It's like, well, that laser is not going to fix what really is a hormonal deficiency problem. And really what you need is the, you know, $10 tube of vaginal estrogen. Thank you very much.
- [29:13]
B
Do you know that there's a paper that women who use vaginal estrogen have less rectal cancer?
- [29:18]
C
Really?
- [29:19]
B
Yeah. I'll take that in your microbiome book about the gut.
- [29:22]
C
Hey, you know, I, I, well this is probably tmi, but like when I use my stuff, I do clitoris to anus.
- [29:29]
B
Yes. C to A. Yeah,
- [29:34]
C
I mean these are the conversations, like women need to hear this information. I think I had a woman say to me recently, well, I lost my applicator, I don't know what to do. And I said, well, you can use
- [29:43]
B
your finger, you've got 10 attached to your arm.
- [29:46]
C
Right. It's like actually toss the applicator and you know, up to like your first or second digit, you can do a better job internally and externally using your finger. And you know your body better than that applicator, which is plastic and unidimensional.
- [30:00]
B
Yeah, totally. I, people just don't have time to learn how to do it properly. And I think that's when people are like, I did, it didn't work for me. Is like hormones work, they're very, very effective. Cells are like, oh, estrogen. But like sometimes you need an androgen, sometimes you do need dhea, sometimes you need it on the vulva, if that's where the pain is.
- [30:20]
C
Let's talk about sibo, small intestinal bacteria overgrowth.
- [30:24]
B
Talk to me about that. SIBO wasn't a thing. Then it's a thing. Then it was everything. Now people are like, is it real? It sounds like it's real because we're talking about like microbiome. Microbiome good. But then we're like, but too much bugs in the wrong place. Not good.
- [30:40]
C
Yeah. So when we're talking about the gut microbiome, we're talking about the large intestine or colon. So obviously farther down the digestive system, when we talk about SIBO or sifo, small intestinal bacterial overgrowth, small intestinal fungal overgrowth, we're talking about bacteria that should be isolated in the colon that have crawled up into the small intestine where they drive a lot of symptoms, gas, bloating, discomfort. And it's never that you just suddenly develop SIBO or sifo. It is usually a sequelae of other alterations in the gut microbiome. I've experienced it, thank God I got rid of it. It was not pleasant, but it was a latent giardia infection that just threw off everything in my digestive system. But I think for a lot of individuals, number one, there are clues on standard stool testing that I can see that kind of send me the direction. Like I don't think we necessarily need to actually test for sibo, but there's enough gas, bloating, digestive issues, and looking at the integrative medicine, stool testing, that will kind of give me a sense this might be what we're dealing with. But it's people that will say things like, I wake up in the morning, my abdomen is flat, I go to bed, I look six months pregnant, or I eat one meal and I bloat out. Like it's so significant. And let me be really, really clear, new onset bloating, new onset bloating, digestive changes, constipation, diarrhea, et cetera, needs to be evaluated. This is not something that you just willy nilly wing it. In fact, oftentimes I will send a patient to go to GI first and say, let's just make sure there's right, rule out the bad stuff, let's make sure there's nothing else going on. Because sometimes bloating can be like a late sign of ovarian cancer, which we know is, is or even uterine cancer, which is something that we want to be mindful of. So if we rule those things out, then it gives us time to play around a bit. But I think for A lot of individuals, it's helping them understand there's a place in the large intestine or colonial where the microbiome, those bugs should reside. But if they start creeping farther up the large intestine into the small intestine, you can have a lot of these magnified symptoms on top of everything else that's happening when we're transitioning from perimenopause to menopause, it is a real thing in my estimation. I think in most instances, by the time someone gets to me, more often than not, they've already seen one or two providers. They don't feel like they've had resolution of their symptoms. And I'm like, there is a very stepwise approach to addressing digestive symptoms in my estimation. And it's why I always say sibo doesn't happen overnight. It's not resolved overnight. It doesn't mean that every single person has to be on these really restrictive diets. It's more about addressing the underlying deficiencies. Is it because you don't make enough hydrochloric acid anymore? Do you have enough digestive enzymes? Do you know that as estrogen is declining, it impacts bile acid synthesis? So suddenly women can become fat malabsorbed. They may have more steatocrit, which is fecal fat. They may say, oh, my stool looks really greasy. It's lying on the top of the surface. And certainly for people in kind of our field, we talk a lot about poop, but for a lot of patients, they're like uncomfortable, embarrassed. They're like, don't talk about sex, and sure as heck don't talk about poop. That's really embarrassing. But I think it's a way to kind of get a sense. So sometimes digestive support can improve and ameliorate symptoms. Not every bit of bloating is necessarily SIBO, but it can happen. I would say maybe 10% of my patients are experiencing. And it is a real thing. In my estimation. SIFO is less common. If you've got fungal overgrowth, there's a whole lot going on that's a whole separate.
- [34:07]
B
You've breached a lot of defenses to get to that point.
- [34:10]
C
Yeah, exactly. Exactly.
- [34:12]
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B
Quince.com notbroken GLP1's helping bloating and inflammation. I've seen it. I've seen it.
- [35:36]
C
I'm a huge proponent. Yep, I'm a huge proponent. I know that the word microdosing and personalized dosing can be triggering to some individuals, so I want to be sensitive to that. I think that there is no other drug in my lifetime that will have as much of an impact as GLP1s. And I think from the perspective of we know that it is altering the microbiome, improving insulin sensitivity, reducing inflammation. I've had patients that have autoimmune conditions. They're put on a GLP1 and all of their symptoms go into remission. Not just the inflammatory weight gain of midlife, which is so frustrating for women. It's like, hey, I'm not looking to be back to a size zero. I'm just trying to not feel like myself and not have all this inflammatory weight gain, less visceral fat. I'm a huge proponent, but I know it can be very incredibly triggering depending on who I'm talking to. So I always like try to respectfully say this is my opinion, this is what I've seen clinically, I'm a huge proponent of them. Not just to mention like Kelly, for so many women that say to me, I didn't think I drank that much and they're on tirzepatide and because they've got, you know, suppression of these like dopamine, dopamine, dopaminergic signals and cravings and desires. They're drinking less or not at all. They don't have a desire to snack. Suddenly, you know, occasionally people will admit, well, occasionally I like to smoke pot. Now they're like, I don't even want to think about that. They just all these, you know, whether it's a shopping addiction or, you know, whether it's someone who's looking at porn too frequently, people are just saying, I just have no desire to do it. So I think that there are so many implications that I'm hearing from addiction specialists and so many other specialties that this is why I feel very confident saying, this is not just a weight loss drug. It is way more sophisticated. And I think that at some point, most, if not all of us will be using it in a targeted, prescriptive way.
- [37:29]
B
Yep. I've become much more. Is bullish the right word? Bullish about it? Because women. The stories that when women come back and they're like, my bloating's all gone. My cardiac numbers are better. I feel like myself again, my LP
- [37:45]
C
went down a bit.
- [37:46]
B
That's bullshit. When they say that's it's genetic and nothing moves it, does that piss you off? Because I'm like, estrogen supplementation decreases it by 20%. Stop saying it's immovable and it's a fixed genetic. And the other thing is, I'm going off on a rant because you gave me the opportunity. People are like, check it. Check it once. They're like, check it once. And I'm like, if you're a man. But it can change. It can change when your hormones go down, and it can change when you start on hormones. And so this whole thing of, like, it's just a genetic, fixed risk factor is actually bullshit. And it pisses me off that when people say that.
- [38:21]
C
Well, and it's interesting, you know, I've had Tom Dayspring on the podcast, like, nine times, and he's become my buddy, and he's just this incredible, incredible lipidologist who myopically focused on women in menopause. So, like, he's just a wealth of information. And he said, you know, Cynthia, do you know that estrogen is a weak PCSK9 inhibitor? So these are very expensive drugs.
- [38:40]
B
I did not know that.
- [38:42]
C
Yes. And so when he told me that, I was like, oh, my God, why are not more women. 20% of the general population has elevated LP. 50% of African Americans. Why are we not screaming? This should be another indication for estrogen therapy. Now, obviously, if you take oral estradiol you'll get a higher, a better response than transdermal. But heck, anything is better than nothing. Like my LP is high, that's genetically mediated, but I can improve that. And so with a little bit of a microdose of tirzepatide and estradiol therapy, it's gone down. It's not perfect yet, but you know, we're, we're kind of trying different things.
- [39:27]
B
Don't measure it. Don't measure it on your book tour. No.
- [39:30]
C
Oh, God. My, my, my functional med doc was like, did you get your, did you get your hormones tested? And I said, we're not testing my cortisol right now. You would be very unhappy with me.
- [39:40]
B
Right, right. I don't want, I don't want book tour on the books. Like, we, we can't have this recorded. This is a temporary problem.
- [39:48]
C
No, I literally was like, at some point I will be on vacation in June and it's will be a pleasant rear free memory of the past six months.
- [39:56]
B
Yeah, exactly. So except for the, the hardcore carnivore people, which they can have their own thoughts. And truthfully, I believe like everybody's diet is uniquely what works best for them. I think at some point in the future we'll be able to like test you and be like, you should probably be 60% meat and blah, blah. Like, we don't have that yet. But my point is, do you think beans are like the absolute best food?
- [40:22]
C
I think it's a great source of soluble and insoluble fiber.
- [40:25]
B
I'm trying to figure out how to get more beans into my life and protein though. Like, it's fiber and protein.
- [40:31]
C
Well, and here's the thing, I'm like omnivorous diets, like when I go to kava, double protein, so double chicken, double steak, and then I do arugula and lentils. And so I get a little bit of plant based protein, I get a little bit of animal based protein. To your point, when a woman tells me I do not tolerate any fiber, I'm like, oh, your microbiome needs some help. And as someone who in 2019 was hospitalized, got a lot of antibiotics for six weeks, my microbiome was decimated. I was full carnivore for nine months. So I see the utility. But I think we are designed as human beings to be omnivorous and so, and adaptable maybe.
- [41:07]
B
Correct.
- [41:08]
C
And so I think, you know, I eat quite a bit of fiber right now, but it's taken seven years, like transparently, I would just share that, that, you know, you can work Your way up. I think for some people especially they've been treated for cancer treatment or they've been on a long, appropriately dosed antibiotics, whether they are tick borne illness. My husband just got treated for tuberculosis. I'm not kidding. In 2025. Yes. In America. Because he's traveled some pretty unusual places. Yeah, it was very strange. So six months of antibiotics, they came. They did dot therapy, came to my house every day. We were the only people in the entire county. Yep. In the midst of me writing the book. And I only interject this to say, like the things that I'm making my husband do in terms of like fermented foods and cycling, you know, probiotic rich foods and probiotics. I mean, just the amount of things that we're hitting him with to help restore the microbiome because it's been decimated. So the point being, I think there are times in our lives where we're more or less amenable to fiber intake. But I think the point is always track and just eat more. So let's say standard American diet, you're consuming 5 to 8 grams of fiber a day. We want to be consuming more than that. But you can't go from 8 grams to 50. Your microbiome needs time to acclimate. You don't run a marathon by just putting on a pair of shoes and running a marathon. You build your way up. So we're building up the microbiome to be able to tolerate more fiber. And I think there's a bio individual approach. Like Kelly may do really well with beans and maybe beans don't do well with me. So I think that there's a degree of experimentation. There's so many options. And it's not just eating salads. Like, I think there's this common misconception that that's the only way you can get fiber. And I'm like flax and chia seeds. Like that is my go to when I'm working with someone who says I don't tolerate a lot of fiber.
- [42:57]
A
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- [44:04]
C
One tablespoon of fresh ground flax and chia seeds. Not only will it help with a little bit of plant based protein and fiber, but help you poop. And that's another thing that you know, it's so important. Just like babies, babies need to sleep and poop where as adults we need to sleep and poop for simple beings.
- [44:22]
B
I love that. It's a great place to end. Some people say if you don't tolerate a lot of fiber or you feel bloated with it. Water, water, water.
- [44:30]
C
I think hydration is important, but it could also be quantity of what you're consuming. So if someone's saying I think I might be fiber resistant, it's like okay, don't eat a can of beans, try a couple tablespoons. Don't eat, you know, raw broccoli and cauliflower, which I hate by the way. Maybe you roast it lightly so it's, it's as you're break, you're breaking things down enough so that it's more easily dig. And you know, maybe you need some digestive enzymes, maybe you need a little bit of tudka, maybe you need some hydrochloric acid. If you're eating more protein. I think there's a lot of ways to address it and do it from a very bio individual place. You just have to be open to the possibility that you need to experiment a bit.
- [45:09]
B
I love it. You are so smart. Thank you for writing this book. Thank you for talking to us about poop.
- [45:16]
C
Thank you for having me.
- [45:17]
B
Any final word of wisdom? You want people to, to know about their gut?
- [45:21]
C
Yeah. So here's the thing. Your microbiome is incredibly dynamic. So small changes that you make today do ultimately lead to a big impact. So don't think from, you know, hearing our conversation like oh my God, I have to overhaul everything. No, no. Something as simple as four to five deep breaths when you sit down to eat A meal can get your body out of fight or flight into the parasympathetic where your body can assimilate, absorb, digest and detoxify. Something as simple as taking a five or 10 minute walk after a meal can help regulate your blood sugar. It can be good for motility in the gut, which definitely changes as we are navigating a decline in hormones. And then lastly, like experiment, Go to the grocery store, try something new. Like we really should be consuming 30 plant varieties a week. And I know that freaks everyone out, but I'm like, listen, you can make a big salad or you can make a big smoothie and throw a bunch of things into it, but just be more thoughtful. Like, don't eat. Like I would say, monogamy is good food. Monogamy is not ideal. Like we do want to have some variety in our diet. Like it really is that important. So just be thoughtful about what you're doing. It really does make a big difference.
- [46:26]
B
I love that. That's great advice. And it's small stuff. It's like throw, throw away the mouthwash, put some flaxseed in the smoothie, like little, little, little. And then all of a sudden you're a lot healthier than you were a year ago.
- [46:39]
C
Yeah, get a squatty potty. If you, you know, get a squatty potty.
- [46:42]
B
We love those. Yep, absolutely. That's a great one. All right, my love, hang in there on your book tour. I'm proud of you. Keep it up. Thanks for being here.
- [46:50]
C
Thank you.
- [46:52]
A
If you found this episode funny, helpful, insightful, please take a moment to follow, rate and share the youe Are Not Broken podcast with someone who might need this conversation too. That support is how this information reaches more people. And thank you for courses, books and my monthly membership and the Caspersen clinic information, visit KellyCaspersonMD.com this podcast and all content from Dr. Kelly Casperson is intended for educational and informational purposes only, and this is not a substitute for individual medical coaching or psychological advice, diagnosis or treatment. Always seek the guidance of your qualified healthcare professional with any questions you may have regarding your health. Never disregard or delay medical advice because of something you've heard on this or other podcasts. Thanks for being here. And remember, you are not broken.