Hormone and Fertility Experts: Dangers Of Not Having A Period! Fasting Can Backfire For Women

If someone's menstrual cycle is irregular, should they be concerned? Yes. Yes. Yes. Yes. Your body is meant to

work like clockwork. And our monthly cycle is so much more than getting ready to have a baby,

especially when we're looking at exercise. And it's important to say if you don't have a period, it's very

harmful to long-term health, brain health, mental health, low energy, mood, and libido. And I don't want the younger

generations to have to go through the stuff that we've gone through. So, it's an important discussion that we need to have. We are joined by four leading

female health experts from very different fields to have a crucial conversation about women's health. With over 80 years

combined experience, they're sharing the truth about what every woman and every man needs to hear. We asked a thousand women to submit

their questions ahead of this conversation. And I got so many questions around fertility, understanding hormones, PCOS, birth

control pill, miscarriage. And I'll say this, Stephen, it's because we haven't had these discussions publicly. When we look at funding in

women's health, it's horrible. like less than 1% is spent on women over 40. Women are living 20% more of our lives

with chronic disease or mental health disorders. I mean 50% of patients with unexplained infertility have indometriosis. But yet it takes women 7

to 10 years to get a diagnosis after symptoms start. But also there are things that we do that will inherently

harm our fertility because we're not taught this and it predisposes you to many medical problems later in life.

And patients will say but I have a really high pain tolerance like it's a badge. And so they gaslight themselves.

And that's what we're all trying to fight here. But there are a lot of things we can do to deal with this. And then I want to talk about menopause.

So in medical school, menopause just gets shoved into a tiny box. This is a scary statistic. So Oh my god,

it's crazy. I just think it's insane. This is why we need to create change.

This might be one of the most important conversations we ever have on the diio because women's health has long been a

total mystery to so many people and so many people are struggling with all of the issues that we're going to talk about today with their menstrual cycles,

PCOS, endometriosis, with diet, with understanding how to exercise as a

woman. It's probably never going to be the case again that these four individuals that at the very top of

women's health in their fields will be in the same place at the same time having this conversation. We structured

this conversation into two parts. They cover completely different subjects, but they're fundamentally interlin. For me,

the understanding that I got from this conversation at this table with these four women has fundamentally changed my

life. It's going to change how I deal with my romantic partner, my sister, my team members that I work with every

single day. And funnily enough, because it's a conversation I wouldn't have clicked as a man, it turned out to be

the conversation that I needed the most. And I don't think I've ever said this before, but if there was ever an episode

to share with a loved one, then this is that episode. Please share this episode with as many women as you can, but also

with as many men as you can. [Music]

Ladies, we should start with some introductions. Could you give me a brief introduction, Stacy, as it relates to

your perspective and your experience and what your sort of bias is as it comes to this debate? When I say bias, I mean

your your your experience and your your research that you're lending to this conversation today.

I come from the exercise fizz and sports med background. Um, so I'm always looking through the lens of activity and

nutrition and how that has a impact on our stress and our stress outcomes and

how we can adapt to specific applied stressors especially when we're looking

at improving health span, improving mood, improving body composition, all of

those things. I've worked with and still work with uh the subset of active women.

Um, I come from an endurance and a high-profile high performance sport background. So, that's where I've gotten

my chops and then brought it over into the general recreational female athlete

kind of perspective. Natalie, I'm a fertility doctor and every day I help patients with IVF get pregnant

because I have an IVF clinic. But my big passion has always been natural fertility after I experienced my own

pregnancy losses. trying to understand how we interact with the world and how that changes our hormones and help women

understand what their hormones are, what natural fertility is, what happens as we age to our bodies, our eggs and our

hormones, and let them be better stewards of their own fertility and their own health decisions.

Mary, I have a background in general OBGYn, so I'm considered to be a women's health

specialist. And it wasn't until I kind of went through my own menopause that I

realized that there was significant gap in my training. You know, hearing watching Dr. Sims on um I think your

podcast talking about how women are not little men really struck such a chord with me and made me realize I was

siloing women's health to the reproductive organs, the breast, the uterus, the ovaries, the vagina and that

if I really wanted to make a difference in a woman's whole health life, this last 30 years, 30, 40 years of her life,

I needed to refocus what we were thinking about women's health for the long term. So I come from

a background in academics. I was a professor for 20 years. I was a residency program director. Stepped away

from that so I could focus on the lack of my own education and knowledge in menopause care. And now I want to step

back into the academic world to bring everything I've learned and change the way we educate our providers. Vonda

I am a orthopedic sports surgeon by training and I sit at the unique juxtaposition of orthopedics and

performance having taken care of elite athletes most of my life aging and longevity most of my academic research I

too as an academic is on subjects of muscularkeeletal aging but many years

ago added a third circle of the whole health of a woman and so sitting in this place it fits directly into the mantra

of my career which has always been I am going to change the way we age in this country and the world because the tool

that I bring to the table is the fact that if I save your mobility I'm going

to save you from the ravages of chronic disease and so the work that I do is not

only educational it's uh research and it's now education of the world about

these subjects explain this to me like I'm an idiot ladies why do we need to have a conversation about women's health and

not just health broadly. I think the statistic that people don't realize on a day-to-day basis is that

women are 51% of the population. We're actually not a minority. We're the majority and yet often our health, our

healthc care access, the research treats us as if we're a niche product,

but we are the majority product. We have to have this conversation

because data show that of the $450 billion dollars spent on

research in this country alone, less than 1% is spent on women over 40.

And yet we are nearly 90 million people. And we make 80% of all the health care

decisions in this country for ourselves and everyone we touch. And so even

though when you look at the the long-term data, women are winning the longevity race here. We're living an

average of 6 years longer than men. But as all of us talk about all the time, women suffer longer.

Yeah. We're living 20% more of our lives versus our male counterparts in poor health with chronic disease or mental

health disorders. And so McKenzie looked at the data and it was for the Gates Foundation and what they found was yes,

we live longer. We've all known that. However, we have, you know, twice as

high of mental health disorders. We're two times as more likely to end up in a nursing home. We are much more likely to

lose our long-term independence from frailty or dementia, much more than our age matched male counterparts. And

that's I think what we're all trying to fight here. And diseases that impact women specifically and only things like

PCOS, endometriosis are extensively underfunded and not researched. It takes

women 7 to 10 years to get a diagnosis of endometriosis after symptoms start. And we know this is a disease that

impacts your entire body in addition to your fertility. But women are dismissed.

They're not taken seriously. and there's not research guiding what we can do in a

lot of these situations to try to help them the best. Why isn't the research there? Why why don't they research if women are the

majority of the population? Why is all the funding going to researching men? You have to think about who was in the

room when medicine and science first started. So if you think about back when the industrial revolution and the

modernization of what we know is medicine, women were pushed out because they were believed to have smaller

brains. thanks to Darwin and not thought to have a seat at the table. So when

you're thinking about designing studies, it was pretty much designed on the male physiology on the male body and then

women were an afterthought. So there wasn't any real in-depth look of well women are different from birth or in

utero XX is different from XY. So all the research has just been generalized

to women. Even things like aspirin for heart attacks and thinning blood

inhibitors. Yeah, all of this all of this was done on men and then just generalized to women and now that we're

having this global conversation on women's health, people are like, well, where is the information specific for

women? And there's just a very small subset. So, we're looking and trying to expand that, but we have a lot of

catching up to do. And that's primarily not only because of what you said, but the shocking statistic is that not until

1993 were women required to be represented in

studies. 1993, I mean, we were all far into our our lives in research by then.

Isn't that a shocking? That's crazy. And there were still loopholes where people were finding ways to exclude women and then

right, we're still not at 50%. No, we're harder to study. You have menstrual cycle, hormonal fluctuations,

even menopause, pre even the animal models. It's not that we're harder to study. It just makes it presumed harder to study.

There's more variables at play, right? It's more of a complexity to the

research, but it's not more difficult. And this is where I bring it in. It's like if a woman had a seat at the table when all the study designs were started,

it wouldn't be a question. It would just have been assimilated in. because we've been so drawn into we have a crossover,

here's one week crossover, next week because of male physiology. When you add women's hormone fluctuations and people

like, "Oh, it's too complex." Right? But it's not. What is it that makes, and this is a super dumb question, but an important

one. What is it that makes men and women different from a physiological standpoint? Because to understand why

research would need to be done separately, we need to understand the differences. Yeah. Well, I mean, we can look from a

morphological standpoint where men have more of our fast twitch fibers. Women

are born with more endurance fibers, which is muscle, right? Uh when we're talking about muscle. Yeah. So, uh men have more of the

ability to do power and and really fast energetic type activities or women are

more attuned to endurance type activities. And this affects metabolism. It affects blood glucose homeostasis.

And when we're looking at bone and bone density, men have stronger bones. Uh they can acquire more load. They hold on

to it better than women do. We see smaller lungs, smaller heart, less hemoglobin in women than men. And that's

an offshoot of what testosterone does. So there are just basic physiological

differences between XX and XY that people don't really assimilate and

understand. And the way I like to say it is you go into a shop and you have a men's section and a women's section and

there are touch points on the external that really identify gender andor sex.

But when you look intrinsically no one is identifying those touch points until now. Also when we look at how we disease

so in cardiovascular disease is is aththeroscerotic disease is the best example. Men tend to have their

blockages. So aththeroscerotic disease is basically the plaques that build up in the coronary arteries around the

heart. Men tend to develop their plaques very early right as those arteries exit

the aorta and dive into the heart muscle. So we get what we call the widowmaker. Okay? It's called that for a

reason because men die and they make a widow. And so that's the left anterior descending artery. Women by and large

tend to not have these larger artery blockages, but their blockages are diffuse and microvascular deeper into

the heart muscle, which is why we present with a heart attack much differently than a man does. And those

we're not teaching our, you know, we're not educating our clinicians as to these differences. Women are considered to

have atypical chest pain. Dr. Wright, 51% of the population is female. Why are why is my heart attack atypical

and a man's typical? But this happens not only at the organ level. It makes

sense that if we have a population with XX chromosomes, a population with XY genetically and the way we express those

genes are differently. But I think we miss the fact that down to a cellular

level, every cell from an XX is expresses these tissue changes, tissue

manifestations differently than an XY. Our lab used to study, we called them

muscle derived stem cells so 20 years ago. Now they're called satellite cells. But when we harvested them and asked

them to behave and in different environments, satellite cells from XX people and XX

animals, women, females were better under the same circumstances

experimentally at making cartilage and muscle. XY male

were better under the same circumstances in making bone. So down to a cellular

level, we express our genes differently. It should be no mystery to us or anybody else that there are differences. And yet

there is the propensity just to lump us all in the same basket and almost say I

almost sometimes feel as pjorative to say, oh the women are different. Of course they're different. Yeah,

we're genetically different down to every cell in our body. Every cell. So, it should be no surprise to anybody, but it it seems to be a

surprise. Seems to be a surprise all the time. Yeah. I get pushed back all the time. There's no difference. Yes, there is.

There is. And it's not just bad. It's just is. Yeah. There's Yeah.

Because at one point that was quite a controversial thing to say, wasn't it? To point at the differences between men and women. Mhm. Outside of, you know, our different

organs. Yeah. You know. Yeah. And because of this research gap and the bias in medicine, um, women have

been misunderstood by their male counterparts in a number of ways. I remember I think it was you, Mary, that was telling me about this whiny women

thing that you were exposed to. When I was in training and and you all may have similar stories and I just

heard a new one the other day, my first patient in gynecology clinic, I'm an intern. I'm very excited. You know, we

have our stacks of charts. That's how old I am. We had paper charts. I pick up the chart, open it up. It's a 40-year-old woman with multiple vague

complaints. She's gained some weight. She's a little bit depressed. Her libido is off. Her blood pressure is a little

bit up. Her cholesterol is starting to rise. And she's seen family medicine. Like we're the third or fourth doctor at

this point. And so my upper level who happened to be male this, you know, it could have been anyone. Walks down the

hall in his cowboy boots cuz Texas. And um and he's like, "What you got?" And I said, "Well, I have Miss Smith,

whomever, you know, she's a 40-year-old woman with." And I list the complaints. And he goes, "Did you check her thyroid? Family medicine did. Did you check this,

you know, a few simple labs?" And he goes, "Hm, you got a WW."

And I said, "What's I don't know this, you know." And he said, "Uh, don't write this in the chart, but we call that a

whiny woman around here." Oh my gosh. And I said, "Okay." He said, "Listen,

women just tend to go through this at this age, and we're not really going to

be able to help her. pat her on the knee, tell her to have some wine, go on date night, you know, she'll get better,

but we're not going to be able to help her. And that stayed with me. Now, I was, you know, a good girl. I did what I

was told. You know, it took me 20 years of internalization to realize this, you

know, I don't want to blame him. He's not a bad guy. This was taught to him. But this kind of thinking, I mean, I saw

this in the ER. I saw this in the O. I saw this in every clinic. And so I've asked other clinicians around the

country and I've heard whiny gyne status Hispanicus total TBD total body delore

like in different regional areas there was a name for this kind of vague complaints from this middle-aged woman

and we couldn't quite put our finger on it and I realized this was systemic bias

built into the system where women and there's historical you know precedent for this the wandering uterus the

hysteria you know these were real medical terms just until like not even a generation ago.

Yeah. They used to put women into asylums. Yeah. Because of hysteria and it was hot

flashes, all the things that that are now known with permenopause. They used to think it was some kind of insanity

and put women into insane asylums to lock them down. But this is pervasive. Not just an OB.

You're not the only guilty. It's every medical subsp specialty has some

culture of for lack of better words blowing women off it right. We're not having the

curiosity that defines medicine. We are supposed to be curious people. But yet

when it comes to this, why do we stop at just seems to be something that happens to middle-aged women, right? it that

that's written in the orthopedic literature seems to happen to middle-aged. Where's the curiosity?

Where was it? Yeah. Well, in X-fist text, you always had the representative of him or they

and the vuvius man and all the angles of the male body, but there was never representation of women. The only time

you heard about a female athlete was all the pathophysiology. You know, the iron deficiency, the female athlete triad,

which we now call um relative energy deficiency in sport. And when you're looking at the

historical idea of sport, the only way women were actually included and

accepted is when they were amenic because then they were quote more like men and then there wasn't a problem with

training them and then they could work as hard. But we know that that's not appropriate. That's a sign of of illness

and overtraining under recovery. So, it is pervasive everywhere. It's not just the medical, but it goes into when you

think about what it means to be successful in sport. It's the power. It's the aggression. It's the unfallibility of being human. And a

woman having a menstrual cycle was deemed a fallibility. So, they're trying to push it aside. This is so systemic

though that women downplay their own complaints. They gaslight themselves. It

takes them a long time to seek care because they're afraid of the response. They are not always honest with what's

going on in their body. I'll say, "Do you have pain?" "Oh, no more than regular." They downplay everything. You

have to really ask. And it's almost the society, I don't want to be viewed as

this way. I don't want to be not taken seriously. And it causes them an to have

an even harder time to get to a diagnosis because they don't feel comfortable sharing some of these symptoms or they've downplayed them in

their life so much. This is why they have to get so sick to often present to even try to get care. And they come to

me almost to a woman after I'm talking about whatever muscularkeeletal thing

they'll say even before they want to describe it to me. They'll say, "But you know, I have a really high pain

tolerance." Yes. Mhm. Like it's a badge because we've been conditioned to not come for any pain.

But I've suffered. I've tried. That's why your arm doesn't move anymore. I've got such a high pain tolerance, but I

couldn't take it anymore. I didn't want to come. And I feel like why does it have to be that way?

So, you train treating both males and females. I I was locked in a room with women for 25 years, you know, and so

it's so fascinating to me to hear how men and women come in with the same

complaint in your clinic, in your fellowship, all those years you spent training, and yet you were taught to

treat them differently, you know, and the urologists say the same thing, you know, who I don't think I was aware of it.

Yeah. There was just that's so much bias. Yeah. I didn't realize. I didn't either

because like you, until I went through my own pmenopause, I might not have paid it attention to

it. Yeah, I may have been less sensitive. I was a terrible menopause.

I see messages all the time in the comments section that some of you didn't realize you didn't subscribe. So, if you

could do me a favor and double check if you're a subscriber to this channel, that would be tremendously appreciated. It's the simple, it's the free thing

that anybody that watches this show frequently can do to help us here to keep everything going in this show in the trajectory it's on. So, please do

double check if you've subscribed and uh thank you so much because it's strange where you are you're part of our history

and you're on this journey with us and I appreciate you for that. So, yeah, thank you. Is that in part because we know very little about hormones as well. When

I was speaking to our audience, we asked a thousand women to submit their questions ahead of this conversation. And one of the most asked questions, all

the most asked questions sort of related to understanding hormones. I think the

conversation around hormones is quite a new one in society and I actually think it's been driven a lot by a heightened

understanding of menopause generally. I think the the conversation of hormones around outside of fertility and the

general menstrual cycle. I can right now draw from memory the exactly what's going to happen in a normal menstrual

cycle. We were taught that, you know, very very well. But when I saw maybe 3

years ago an academic paper that showed all of the locations of the G-coupled

estrogen receptors in the human body, what's that? I lost my mind. So basically, where are

the estrogen receptors in the human body? And they're everywhere. The brain, the bones, the muscle, the gut, you

know, the the every almost nothing. The the the endothelial, the lining of the

individual blood vessels around our heart, you know, it's really radical to me to think about how all these sex

hormones are the progesterone, estrogen, testosterone, hormones are everywhere.

What is a hormone? They're not actually sex hormones. hormones are your body's communication system, right? So, it is really how your

body is sending out messengers to communicate. So, a hormone is dictating an action and I think there's going to

be a lot of great discussion. But one thing that I think is very important to your point, Stephen, is even things that

we were readily taught about the menstrual cycle and estrogen, progesterone, testosterone, the public

is now becoming aware of because we've not done a good job at public education that this is what's really happening in

your body. this is what your menstrual cycle is. This is what happens when you go through menopause. This is what

happens when you're trying to train for a sport. We haven't had these discussions publicly that we are seeing.

And I think that is highlighting interest in all of this even if some of us were taught some of this. But when it

comes to hormones there, everybody wants really easy fast. Draw my level. Tell me

what to do. Give me a medicine. Fix it. And I think the most important thing to understand is that by definition, your

hormones are dynamic. Your body is responding to the hormonal signal it sees and determining what next signal to

send out. So constant fluctuation throughout the day in response to multiple stimuli. And that's how it's

supposed to be. If we didn't do that, we'd all be dead. It's a symphony. But that makes it really hard for somebody to understand

on the other end who's not in medicine who says, "Well, is it my hormones?" Because there's no one test that's going

to give you one answer. You have to really interpret it in context of the full body. And it makes it really hard

for practitioners who do not understand the hormones as well. And we see a lot of mismanagement of hormonal scenarios

and situations right now that are actually detrimental to patients. So, I'm glad you're having this discussion

because that's not a stupid question. What is a hormone? Many people don't really understand that.

What is the I really want to make sure that if someone for both the men that probably have less understanding but also from our conversations I've

realized and the feedback I've gotten a lot of women don't understand their own hormones and their own menstrual cycles.

What is the most basic level that we have to start at to give people an understanding that we can then build on

of what's going on here? I was say I want to get rid of this graph. Okay. So that leave it out. Leave it

out. But it it shows just a textbook of what a menstrual cycle is is, but it

doesn't show the daily perturbations of estrogen and the luteinizing hormone pulses and all the things that go as

Natalie is saying to make it to make it work. You see two organs there, the ovary and the endometrial lining. You're not

seeing the muscle, the bone, the brain. All of those organs are affected by these normal monthly fluctuations.

Yeah. And the conversation that we're having now in research methodology is

the fact that there is no real definition of normal cuz every woman's cycle is variable. So when we look at

this, everyone thinks that this is normal but we don't actually know if that is for the fact that a woman's

variation this can change cycle to cycle. This can change cycle to cycle. Sometimes we have

an ovulatory cycles. So until a woman can identify what her own normal is, we

can't rely on this graph to actually explain to them. How does a woman know what their normal is versus, you know, because a lot of

women are on birth control pills since a very young age. So I think my partner Melanie, she's she was on birth control

for about a decade. So she like didn't have her cycle and then it came back and it was every I don't know 60 90 days.

Mhm. And then she changed her diet a little bit and it kind of went down to 30 days over time. But I don't think she knew

what normal was. Is there such thing as normal? I mean there is what should be normal for you. So you should have a regular

predictable period which means that you are having a menstrual bleed at a predictable interval. It can range

person to person but for you really it should be within a couple days monthtomonth. I always tell patients I

should be able to give you a calendar. You should be able to take your finger pick when your next period is coming and within a few days be accurate. Now

usually that range is somewhere between 25 and 35 days for the average person. when it starts to get shorter or longer,

it can be a warning sign that something is going on. When it comes to the menstrual cycle, because I think we're

going to talk about these hormones really well, and I talk about this every day, let's give a one minute

explanation. If we think about to Stacy's point from the brain, the brain is sending out pulses of hormones, but

FSH drives egg growth. It's called follicle stimulating hormone, and each egg is inside a follicle. So, you have a

group of follicles inside the ovary. FSH comes from the brain, grabs one of them and gets it to grow and it makes

estrogen and this estrogen from the ovary as the egg is growing is called estradiol and it's the primary type of

estrogen in your body. So it is rising and when it gets to a peak level and the

body is so fascinating because it's 200 pogs for 50 hours is a very exact amount. Then the brain says we must have

a mature egg and it kicks out a surge of luteinizing hormone or LH and that is

going to allow the follicle to rupture the egg to be released and the follicle to reform and then become a corpus

ludium and then the brain's going to send out pulses of LH giving you pulses of progesterone. So Stacy's point

that's an average and those numbers on the little graph are nowhere near accurate because progesterone goes up

and down the entire second half of the cycle known as the ludial phase. What's progesterone? Progesterone is also made from the

ovary. So, the two main hormones when it comes to a premenopausal female are going to be estrogen and progesterone.

Progesterone is the progesterational hormone or progreg. It is going to change the endometrial lining and it is

essential to get pregnant. It opens and closes the implantation window within the uterus and it completely changes the

physiology of your body. And we're going to talk a lot that is why in the ludal phase your body works differently when

you have progesterone and the lutial phases after ovulation when you have a corpus ludium. So when LH is coming from the

brain you have a corpus ludium it makes progesterone. This is the second half of the cycle known as the ludal phase. The

first half when you have estrogen only is the follicular phase. So you have an estrogen dominant phase and then you

have a phase where you have both estrogen and progesterone. And your body is made Yes. So we have our estrogen

dominant phase, the follicular phase, and then we have we have both estrogen and progesterone here in the ludial phase. And your body is made to function

differently in these because in the progesterone side, it's preparing you for a pregnancy. It thinks every month

you might get pregnant and it starts to change how your body's going to work on a cellular level. But if you don't get

pregnant, that progesterone level is going to drop and the cycle starts back over. And from um like a exercise and sports

Yeah. point of view. When we get into this, the progesterone's job is to build this lush endometrial lining and it

creates a lot of glycogen storage. So, we often hear about glycogen in the muscle and that's what we're using for

fuel. It has a way of shuttling a lot of the carbohydrate away and storing it

into the endometrial lining, which is why we see differences in intensity and the way that a woman can respond to

exercise if she has ovulated. So is this in preparation of a potential baby?

Yeah, correct. Yeah. In the second half of the cycle, your core body temperature increases, your resting heart rate is

higher, your heart rate variability is lower, you have increase in fatigue, you have an increased appetite, your body is

shifting function in case an embryo comes in so that it can start to divert energy and change what it is doing right

down to your immune system changes. And that's roughly from day 14 roughly. Roughly. Yeah. Yeah. At ovulation, it's

about 3 days after whatever day. If you'd like to be specific, it's about 3 days after ovulation until when you get

your next period. Yeah. You all talk about how our menstrual cycles can be a broader sign of whole

body health. Mhm. And um so should if someone's menstrual cycle is irregular, should they be

concerned? Yes. Yes. I thought you were going to say no.

How irregular? What's like if I'm not getting my menstrual cycle? Absolutely not good. You should go see a

doctor. Yeah, if your cycle is irregular, if the calendar trick, you're putting your finger and it's nowhere

near when your cycle's coming. Or I have women who say, "Oh, there's no way I could predict it." Or, "I know it will

come, but it'll come every 4 to 6 weeks." Your body's meant to work like

clockwork when it comes to your your hormones and your menstrual cycle. And yes, you can always have one abnormal

month, always. But when you consistently are having irregularity, that is a sign

that something else is going on. It's one of the biggest red flags that we have for early hormonal health or

systemic problems. But to your earlier point, Stephen, we have a generation of women on contraceptive options who are

not tracking their cycles. We have women who are not taught how to track their cycles. They don't know when ovulation occurs. They don't know how long their

ludal phase is. If I say the first sign of ovulatory dysfunction or having a problem with your cycle is a short ludal

phase, well, you only know that if you're tracking when ovulation occurs because otherwise you could still have a

regular cycle, but you don't know that something's abnormal. And that lut your phase again is the last the last half of your your cycle.

Exactly. But I think that the conversation that's happening now is so not just at this table but in society

that our monthly cycle is so much more than getting ready to have a baby

because I think that none of us knew this. No. Because at 17 I wasn't that interested

in having a baby. So it didn't occur to me that I should care. Right. Right. And it's the only time if you're

thinking about it in that way that you're worried about your period is if you don't have one and pregnancy, right?

And so if we're shifting the conversation to this is physiology, this

is has to do with every part of female physiology, maybe it will be easier for people to

know, right? Yeah. I often put it with u my athletes that it's a marker of health that if you

are able to take on the load of training, the load of travel and maintain your normal menstrual cycle,

then you are robust enough to be able to progress. But if there becomes a misstep

in your menstrual cycle, then we need to look at all the stressors that are and the allosic load and pull you back and

see what do we need to address? Do you need to eat more? Do you need to recover more? what are the things that are

missing to bring you back to normal? I was diagnosed with polycystic ovarian syndrome in medical school and so like

every medical student of course it was like gloom and doom and I you know thought I had the most extreme case ever

known to mankind. It was really just garden variety PCOS and I had very serious boyfriend quickly engaged you

know looking forward to having a family with him starting a family with him and the terror around my infertility and

what the impact was. What was never taught to me and what I didn't understand until much later was the

metabolic impact. Like PCOS is a symptom. There's nothing wrong with my ovaries. They're just responding to this

high insulin level I was born with. And no one really sat me down and talked to me about my first research project was

women with irregular periods and the risk of developing gestational diabetes and and you know I didn't even know what

insulin resistance was at the time. And now we're coming to understand that, you

know, when these young women are coming, you know, I only do menopause now, but before I left that practice, you know,

when women were coming with the regular cycles and we were making these diagnosis, immediately I was launching into the discussion about her metabolic

health long term and what this, you know, it's a gift to know this. So now we can start making interventions,

nutrition, diet, exercise to give you a better system to deal with this thing

that you were born with and her fertility. Of course, a huge amount of women have PCOS and I think that's one of the leading one of

the leading one of the top causes of having irregular menstrual cycles. You you mentioned insulin resistance and

metabolic dysfunction there. And you said something like diabet gestational diabetes, diabetes in pregnancy. So someone who

was non-diabetic before pregnancy and then develops diabetes. So her blood

sugars have now reached a threshold where they are higher than normal and can cause you know problems for her

pregnancy and herself long term. And up to 50% of those patients de who develop

diabetes in pregnancy will develop type 2 diabetes within 10 to 15 years after

that gestation after being pregnant. And so what we know now is like we have warning signs of this well before

pregnancy where we can set these women up for success. Before it's just we wait till we make the diagnosis, everybody

gets their glucose test and off you go. But now with this PCOS diagnosis, we are

monitoring earlier. We're starting her on the nutrition. You know, we're treating her like a diabetic with nutrition and exercise recommendations

rather than waiting till she she reaches the criteria. Stephen, having infertility, this is a scary statistic.

It predisposes you to many medical problems later in life, including an 80%

higher chance of having a heart attack, 75% higher chance having metabolic syndrome, higher risk of cancer, and

early death. Why infertility? Well, it's not exactly that infertility is causing this, but it's that for many women,

we'll use Dr. Haver's example, you're healthy until you get this diagnosis.

It's one of the first warning signs your body's giving you that there might be inflammation and insulin resistance or

something impacting your hormones, your menstrual cycle, your ability to conceive that if it is not corrected now

is setting you up for many problems down the road. PCOS is a example of this

because in PCOS you have a lot of eggs inside the ovary. It's actually something that genetically runs in

families. likely there's something that happens when you're a baby inside your mom that predisposes your ovary to not

lose as many eggs as it should and it changes how they respond to insulin. So what happens is you end up having more

eggs on an average. Your brain doesn't know this and sends out the average signals but that gets diluted amongst

all the eggs and so you're not getting into these ovulatory stages of Stacy's favorite graph here. Well, what happens

from there is that you're actually in a relatively lower in estrogen phase than you should be. You never see the

progesterone. And what happens is you start to completely shift. The ovary itself actually becomes insulin

resistant. And what this means is that throughout your entire body, you start

to develop high glucose, which is the blood, right? That's your blood sugar. Your blood sugar is the fuel for all

your cells. All your cells need glucose. Well, insulin is the hormone that helps that glucose go from the bloodstream

into your cells. Well, in insulin resistance, when your body sees high glucose all the time, it starts to send

out more insulin saying, "Hey, we need to get this into cells, but the cells start to, oh, I'm used to insulin being

here, so I'm not going to respond." It's going to take a higher insulin signal to get the cell to open up the door and let

glucose comes in. This becomes very problematic especially in we'll say PCOS

because that insulin is very inflammatory causes you to get extra fat stored in different places. It also just

completely changes how your body your metabolic health in general but also your hormonal health and in your brain

because your brain sees this and says why are we keeping glucose in our in our bloodstream is what's going on heightens

everything. And so this resistance to insulin actually shifts how your brain's

going to respond to hormones, therefore the hormones it's sending out. And it's a self-perpetuating cycle. And a lot of

when we talk about lifestyle mechanisms to improve hormonal health, which I know that we all will, a lot of that is

targeting improving insulin resistance and combating inflammation because those

two players, a lot of it is controlled by the world around us and what we do to

some degree. And especially if you have an underlying diagnosis like PCOS, endometriosis, which is a chronic

inflammatory disease, autoimmune disease, you're at even higher risk. I always say your scale is already tipped

in a way that's going to be really hard for you. You have to make active steps to fight what is happening inside your

body. We'll talk about some of the ways one can reverse their PCOS, if that's even a possibility. Um, but again on the causal

factors, is it something So my girlfriend's got PCOS. She's been very public about that. Um, is it something

she did? Is it something she ate? Is it She was Is this the way she was born? So, she was born with a predisposition

of having too many eggs. You lose most of the eggs inside your body when you're a baby inside your mother's womb. You lose the next biggest set before you

ever have your first period. Now, if you don't lose them for some reason, you're born with more and it interferes with

how your hormones are supposed to communicate leading to this metabolic issue and this insulin resistance. She

did nothing to cause this. Nobody with PCOS caused it. However, what you said earlier, oh, she changed how she ate and

her cycles got more regular. You can influence the severity of the

symptoms that you experience with it. So even if you don't cause your disease cuz you did not,

choices you make can make it absolutely can make it better or worse, just like any disease.

And when you use the word insulin, I I think of or insulin resistance, I think of sugar. Mhm. Yeah. Because glucose is sugar

essentially. And many people, and I'll have patients tell me this, I don't need to worry about insulin resistance

because I don't have diabetes or it's not in my family. And we've so we've ingrained this word insulin resistance

or talking about glucose or checking glucose with a diabetic or pre-diabetic state. But the world around us honestly

promotes insulin resistance. It's it that's how our bodies we live in this

obesogenic environment. I mean there's no doubt at least in the US you know and

most industrialized nations our environment is what we call obesogenic insulin you know and insulin resistant

so it you have to fight against kind of the systems that are in place now for most of us unless we have some genetic

predisposition to just be you know magical um to because the way we process

food the way food is delivered to communities the way you know our lack of exercise you know everyone's working

from home now just just modern life is is really you have to fight against.

One of the questions that came in from the audience was I would like to know how best to manage my PCOS.

When it comes to managing your PCOS, targeting those two factors that we talked about earlier, insulin resistance

and inflammation are really the key. And I'll let these two speak to a little bit of some of the exercise changes that we

can try to impact. But what I'll say is that the best way to decrease inflammation in your body is going to be

to start by focusing on your gut. Your gut health controls a lot of the inflammatory burden that your body sees.

The foods you choose to eat, they can be both helpful if they have a lot of fiber in them. They can feed your gut

microbiome, which is important in estrogen metabolism, but they can also

be very harmful if they are ultrarocessed foods that are even causing more inflammation, not feeding

your gut microbiome at all and worsening. So, I always say it's like a scale. If you think every little food I

eat, it can make my insulin or it can make my inflammation better, it can make it worse. And so how we structure the

food that we put in our body is one of the biggest changes the majority of people can make that is going to make a

difference. And that's going to be a very plantforward diet. Doesn't mean it's plant only, but plants have fiber.

Fruits and vegetables have fiber. So we have to make sure we're getting fiber as

a big change. That's what we see. I see a lot of patients with PCOS specifically being told I shouldn't eat fruit. I

shouldn't do this. I I need to avoid do the ketogenic. You need to do keto. Yes. So, we see people avoiding certain

food groups. And I always say it's not a really sexy diet, but it's a it's a diet we all know. Lots of whole foods, fruits and

vegetables, healthy fats, healthy sources of protein, avoiding the ultrarocessed foods. That's going to be

probably the biggest change most people can make. In addition to foundational changes of your day, which is going to

be sleep more, that is when your body fights inflammation, fights insulin

resistance. work on decreasing chronic stress. To Stacy's point, you're not

running from the bear. So, your body is not using that challenge, but you get a

email. You get stressed and your body releases a lot of glucose so it can have

sugar and fuel to run from a bear and there's no bear, right? And previous days that would happen and then you'd go

run and that glucose would go into all of your muscles and your body would go back to normal. But now, we're

chronically stressed. So, actively decreasing stress and then exercise,

building and using skeletal muscle is one of the most effective ways to combat insulin resistance that exists. And

since 80% of patients with PCOS have insulin resistance, a large portion of

women with infertility, even without PCOS, have insulin resistance, that is a

huge thing that people are missing, especially when it comes to the exercise discussion. And I know you guys probably

have things to add on that one. No, but based on what you just I just took a phone call this morning from a patient

when and it's just such a typical conversation. She doesn't like the way

her body looks. Her solution is not to eat. It's this

happens almost every day when I'm talking to people. It's we're having coffee for breakfast. We don't eat till

midday when we do eat. So the the gut reaction because of the way many women

are raised is that we're going to starve ourselves which is the opposite of good when it comes to physiologic wholeness

and then you don't have the energy to do the kind of exercise you need or on the other side the response is I am going to

work so hard every single day that you actually increase your stress there is

over there is overtraining so you're just getting behind the eightball with starving yourself and

overtraining. None of which are going to solve either the core problem due to PCOS or the core problem in any stage of

a woman's life. Right. And this is where we look at the socioultural effect of what a woman is supposed to look like.

Yeah. And that's the thing that I really pushing out. It's like we want to think

about how strong we can be and how much muscle we can build because muscle is a massive metabolic help. Mhm.

And as as well as bone, right? So, we talk about it and then when I get the

push back of, oh, I'm going to do fasted training or I'm going to fast till noon. I'm like, wait a second. Not only were

we going to interfere with our circadian rhythm and our hormone pulses, we're also acutely interfering with our

appetite hormones because if we're looking at gerolin, which is our active form of of our appetite, makes us

hungry. It's elevated with cortisol. And so if we're thinking about that elevation and we're not doing anything

to drop it and tell our body we have food, then it goes in and directly affects our neuropeptides, which then

affects our hormone, our hormone pulses. So when a woman's like, I'm just having coffee for breakfast and I'm going to

hold my fast. It's like, okay, well, here we go. Cortisol is going up. As Gary, you're going to get hungrier. Then you're going to learn not to respond to

that hunger. You're going to hold your fast. And we see from the research that women who do that end up craving more

simple carbohydrates in the afternoon moving incidentally less and contributing to poor sleep because

they've now phase shifted. So when we're talking about sleep and how important sleep is, we also have to think about

the circadian rhythm and how it is affected by food intake, light, darkness, and all of the things. And we

need women to understand we want to build muscle. We want to sleep well and that requires food. Well, and it this

goes back this whole thing you just said goes back to very early in this

conversation where I was talking about sometimes we like to focus on the bright

shiny gadgets when we haven't taken our health from fine to optimize because everything you

just talked about it isn't a gadget it's basic lifestyle

in the medical model of PCOS when I'm talking about what we're taught and how

we train our clinicians. We go into the, you know, we we aren't

taught a lot about disease prevention or and I hate to use the term root cause because I think it's been usurped by

certain members of, you know, the wellness community. Take it back. Yeah, we're going to take it back. And so, especially for PCOS, I was taught to

give a patient birth control pills or Clomid when she's ready to get pregnant. And so nothing nothing around nutrition,

exercise, lowering inflammation and I was a program director until 2018 and

there was nothing in the curriculum around this which affects at least 10% of women probably more this condition

that how important lifestyle is. You know, she went on for 10 minutes about

all the lifestyle change, which is amazing. Which is amazing. But but patients, but I'm sitting there thinking birth

control pills, birth control pills. I mean, that was a knee-jerk reaction. I mean, I was treated for my own polycystic ovarian syndrome for 20 years

with oral contraceptive agents. And I learned online through chat rooms about

the nutrition end of it. Yeah. when I have athletes because we

see a higher percentage of PCOS in successful female athletes. Why like what do I do? And it's looking at

what kind of training they're doing. So, we're putting this more short, sharp, high intensity to get that post exercise

response of anti-inflammatory, growth hormone response, all of these things that then bring down total body

inflammation. And then we're very careful about food intake and when we're doing it and what kinds of food so that

they don't have to go down the route of oral contraceptive pills because that to them has an effect on their performance.

When we're talking about the top end and when we bring it back down into recreational female athletes, we can do

the same thing. It's just we have to educate and say these are our lifestyle choices and then these are our medical

choices and what's optimal for your life at this point. Mhm. It's important to say at this table, and

we all talked about it last night, you need to have a period if you're not preventing a period with hormonal

contraception and you're in your reproductive years. Because very often women with PCOS or hypothalamic

amenorhea will say, I don't have a period, but I didn't really like that anyway, so it doesn't bother me, right?

How many women have said, well, I didn't get my period for a year, but that was fine by me. But that's not fine by your

body. That is hypoestrogenic time. It is low estrogen. Yeah. Very low estrogen. It's bad for

your body on so many reasons to be low estrogen during these crucial bone building years. But for we're talking

about how your hormones communicate back. It's very harmful to long-term health to have low estrogen

at all. Brain health. But yeah, but especially in young years when you're still developing.

Why would a woman say that she didn't want to have her period? I mean, this is a super naive question as a guy, but I understand it's painful. I mean, do you want to bleed from

Do you want that? I mean, if it was a choice now, actually knowing now what I know now

and for my own young daughters, I'm like, we have got to make sure you have a period. But when I was young, I was a

dancer and an athlete. I had very low body fat and I wouldn't have periods for 6 to9 months. And I'm like, yes.

Do you know what's interesting? I was thinking of Mel. She because of what she's been through

and also because she's listened to the conversations I've had with all of you and she understands the value and

importance of her period, she now celebrates it. It's like a celebration in our house when it arrives because

because if you understand the importance that it has in sort of full body health and the role it's playing, then the

pain, the downside is weighted against your understanding of the upside, which to her means she's

healthy, she's fat, hormonal health is working, things are great. And that's the conversation shift that I'm hoping is gonna instead of

being a detriment and a downer and talked about she must be on whatever derogatory yes derogatory things are

said about us that oh my gosh she is so healthy. Yeah. I remember sitting in a high

performance meeting just maybe three years ago and the leading athletics coach stood up and said I know when my

athletes are ready to perform on the world stage when their periods stop. And all of us went what?

It's like no, that's the time where like we have to really look at your athlete is getting ready to crack and be

injured. And it's still this pervasive idea and it's still pervasive even in the fitness

industry that losing your period is okay cuz that means you're training harder. They actually are very resistant to

getting it back. Yes. Like it's a sign of failure of their sport or their athletic endeavor

because this is is so pervasive. And I think that's why it's important to have these discussions. And I love hearing

that Mel now says, "Yay, my period is here." Because that's a sign of hormonal health and things are working well

because that is how we should feel. But I think the other part of it is for women who have mayoria or heavy bleeding

and heavy cramping. They don't realize that they can get help with that as well. Mhm. And that's a conversation that isn't

followed through when we're like, "Yes, get your period, but if you're someone who suffers from really bad cramps, we also have to educate that there are

things that we can do to help with that. Does the size of the bleed matter?" Because she turned around to me the

other day and she said with her last cycle, she said that she didn't bleed much and she seemed slightly concerned.

Obviously, I had no idea what to say to that. It depends. Congratulations. Well done. I'm so sorry. minora. So we have definitions

and there are you know we don't walk around with measuring cups generally between our legs to measure how much blood's coming out each month. But

but women know but women know your period should not cause you with modern you know period

products your cycle shouldn't cause you any stress in your life. You should just

roll with it, right? And so that's when I'm like when is it a problem? Shouldn't bleed through your clothes. You should be able to sleep through the

night. You should be able to get through an athletic performance. You should be able to do X, Y, and Z. Now when we do

start measuring and you should not be anemic. So I'm not waiting till anemia. I am anemia is low red blood cell count

you know to the point where your performance is affected. Your ability to carry oxygen is effective. So the red blood cells are what carries oxygen in

our bodies. And women who have heavy periods however that's defined can lead

to anemia. But the first thing that we notice is their feritin is dropping. That's the first sign my do my daughter

we just had some blood work done. She was feeling a little fatigued and her ferotin and iron saturations were really

low and I was like talk to me about your period. Turns out she's not eating a lot of iron rich foods. So we're dealing with that. But you know we can get so

far ahead of this and looking at these ferotin levels the transfer you know these iron studies before she's actually

anemic which is like the last thing that happens when her red blood cell count drops or they become so small and what

we call microitic. you know, we are we need to do a better job at recognizing these things. We're not going to walk

around and measure how much blood's coming out because I could maybe squeak out 200 cc's, you know, a period and you

could be 300 and we're both doing fine. You know, we both have great. So, I think it's really looking at, you know,

how much bleeding is too much. Now, how little is too much? That that's probably better in your Yeah. Is any change from what you

consider normal? We would all say this is a normal amount. So if it gets heavier than that or less than that and

it stays that way, that is concerning. You can always have a one-off. Estrogen is the driver of growing the uterine

lining. So if you have a lighter bleed one month, we are concerned that you did

not grow as thick of a lining. Your body didn't see as much estrogen. Most the time you ovulated earlier that cycle,

your cycle came a little bit sooner than you're used to it coming, and it's not quite a big deal. But this can be

concerning if we see consistently light periods, especially if we have history

of progesterone contraception, which progesterone thins out the lining and estrogen grows it. So progesterone

actually stabilizes it, but for the sake of the discussion, we'll say estrogen grows it, progesterone thins it. When

you only see progesterone, like a progesterone IUD, the progesterone shot, even continuous birth control pills,

because they give you a type of synthetic estrogen and progesterone every day, your uterine lining gets

thinner and thinner and thinner. And so we see it can take months to return to

normal after coming off of hormonal contraception. You also can get damage to the endometrial lining. There's stem

cells in the endometrium that regenerate every month after you bleed. They regenerate so that the next group can

grow in response to estrogen. And this can get damaged from typically anything inside the uterus. So most commonly this

is post birth, you know, a traumatic birth, a retained placenta, a DNC

procedure, which is sometimes used after birth or in a miscarriage or even IUDs or intrauterine surgery. and it can form

scar tissue in the uterus that can cause a light period. So if you said, "Oh, Mel

had a miscarriage and had this procedure and now her periods are lighter." I'm highly concerned.

Versus amen. Yeah. So that is concerning for scar tissue in the uterus. Okay. If you said, "Oh, she was on a birth

control pill for a while and now it's a little bit lighter." I'm less concerned that's probably going to get better. or if this period came closer together

or if you traveled around the world three times this last month or so one one off is no big deal but a

change from your baseline can be concerning in addition we should say that that graph is beautiful but you

know your thyroid your pituitary gland it makes prolactin prolactin also changes the endometrium so there's

subtle signs of other hormonal issues that your menstrual cycle is the first

warning sign that something is off what about pain She 2 months ago she had like excruciating pain that I've never

seen before during her menstrual cycle. Well, it's not pleasant to have your uterus contract and expel its contents

in any form. But what if it's like way above the norm? One time way above the norm is probably

situational based on other things that are contributing to inflammatory burden or response. your body is also healing

from a the corpus ludium's a cyst on your ovary that can also feel painful and at the time of your period it is

also healing so there's multiple things that can cause pain to Vonda's point so many people say I

have a high pain tolerance this is okay because we don't talk about our own pain

so I don't know if my pain is normal compared to somebody else's your pain should not keep you out of your

activities of daily living you shouldn't call in sick to school call in sick to work, cancel dinner plans with friends

consistently. Again, everybody can have a one-off month where something is off. But if this happens every month, oh,

it's my period. I'm going to cancel that. That is a warning sign that something else could be going on.

Endometriosis, adnomiiosis, and uterine fibroids. You mentioned the word iron a second ago, Dr. Mary. What is iron got to do

with this? And what is iron? So iron is an element that is in our diets and we

do tend to store quite a bit of iron in our bodies and it's an essential when we look at the structure of the red blood

cell and of hemoglobin specifically. So hemoglobin is the actual molecule that

is inside of the red blood cell that carries the oxygen. So iron is really critical to the formation of healthy you

know iron carrying red blood cells and we we store iron in our bodies and so and a lot in the bone marrow and in and

it's stored in this particular molecule called feritin. So when we're measuring ferotin levels in the blood that is you

know the first sign that your iron stores are getting low is when we see these low feritin levels. Are women more

iron deficient than one would think? Like is the general population iron deficient or what do you tend to see

when you run lab tests? A menstruating woman. Yes. A menstruating woman is is often

iron deficient. Yes. And I we I do see it in our post post-menopausal patients as well. That's

usually nutritional and inflammation related. So ferotin is also something

that will decrease in in times of chronic inflammation. And so you're not able to utilize the iron that's coming

in and store it because this inflammatory state is kind of inhibiting that. So in a menstruating patient, I'm

always thinking is she bleeding too much the first time, you know, and is that bleeding menstrual? Is it coming from her rectum? Is it coming from her

gastrointestinal tract? You know, does she have gastritis or, you know, we have to go through the, you know, the algorithm of why that might happen. In a

post-menopausal patient, we can remove vaginal bleeding from the issue, you know, uterine bleeding, a period, but

then now I'm looking at nutrition. And I'm looking at exercise. I'm looking at inflammation as causitive factors. And the global pitch here is the World

Health Organization estimates that roughly 30% of women aged 15 to 49 worldwide are anemic with iron

deficiency being the leading cause. And in some reason regions of South Asia and subsaharan Africa prevalence can be up

to 50% of women are anemic with iron deficiency being the leading cause. H

you noticed the norms have changed. So it depends on who you read.

Yeah. again, you know, when you're looking at male male normative curves versus what you know, we're we're tend

to accept lower levels for a female. But now that we're looking at performance and, you know, looking at other factors

besides just what is this feritin level, um there's a lot great new research

coming out that we are looking at this differently and that that we're in our clinic, we are looking for 60 to 100 for

a feritin level to be considered optimal. very different than, you know, the baseline for, you know, keeping you

out of out of a hospital versus you functioning at your absolute best.

Yeah. Because the norms that often get measured for us because they tripled, right? They were

15 and then they went up to to 40. So now they're saying 20 and above is normal. And when I look at a lot of

women who are sitting 20 to 30, they can't get help. They cannot get help. And it's like,

whoa, it was maybe four or five years ago. If you were below 50, then we would

look to get help. But now with the norms that have shifted with the sicker population,

we can't get women help unless they are below 20. So when we say normal, I think

this is important for everybody watching or listening. Normal in medicine means

common, not non-pathological, okay? Not bad, you know, doesn't mean it's not

bad. And so norms shifting meaning we're getting sicker as a population and we're

willing to accept lower levels although they're not optimal for health. The lab reference range what they say when you

get your blood work drawn and you see the reference range is based on population averages. And so if the

population is more anemic this is going to accept a lower levels being normal

even though they're by no means optimal. And I think that's one thing we all talk about is well how are you feeling your

symptomology? What do we see? And you have to interpret blood work in context of the whole person and what is

happening. And that is one issue we do see with getting your own blood work drawn or these online companies when

nobody's interpreting it or helping you interpret it on the other end. You see something that is in a normal range but

it's not at all optimal for you and it could be the reason why insurance. Yeah, exactly. I want to talk about

endometriosis. I we have a team member who's been with the Davosio since the very beginning called Liv. Yes.

Are you familiar with Liv? I am. So at age 13, she had her first period and she experienced agonizing pain with

heavy bleeding. At age 14, she was put on the pill to manage the symptoms. Between age 15 and

24, she continued to have severe stomach pain which resulted in multiple A&E visits. She was often dismissed as

having gastriisitis. Mhm. And it led to having her appendix removed. Oh my god.

Why'd you say oh my god can get surgery? But she had major surgery and

um I' I've seen this course before and it's it's devastating cuz she's going

years and years and years now of Yeah. age 25 she came off the pill to see how she felt without it but her

periods worsened and she fainted from the pain. So she went to accident and emergency. At age 26, she got an

ultrasound which suggested endometriosis, but no NHS diagnosis was given.

We ultimately had a conversation with you on the podcast, Natalie, and she felt very heard and she was actually

there. And so afterwards, Jamaima in the team, who you you guys know, um told Liv to come and speak to me. And Liv told me

after you left about um the symptoms, did she speak directly to you at that time? She did. Okay. So, she came and

she spoke to us about her endometriosis, which is the first time I'd ever heard of it. Um, and then we offered to help

support her privately so she could get private support with it. Um, and she got

an MRI scan privately, which confirmed stage 4 infiltrating endometriosis. Oh gosh.

Liv then pushed um on with her NHS appointments, the National Health Service in the UK, but the pain was so

much that she took me up on my offer to pay for it privately. So, we paid for it privately. Uh, and the endometriosis by

that point had spread to her bowels and pelvis. And I've got this picture of this four cm cyst. If you're all

faint-hearted, I mean, I don't know where we'll put this on the screen, but this is from her operation. Yeah. It's called an endometrioma. It's

huge. For anyone that can't see, it kind of looks like a tumor. Yeah. Um, next to her ovaries

and it had spread at that point to her bow and pis pelvis. It had become about 4 cm big. Her ovaries were stuck

together and attached to her womb and her bowels. She then needed to book an appointment for surgery. And before the

surgery, because of the scale of her endometriosis, she had her eggs frozen to protect her future fertility, which I

guess came from your advice. This process took her 7 years and she was in

pain for 17 years because she did not get a diagnosis. Her story is unfortunately not uncommon.

This is a very typical story for somebody who suffers from endometriosis.

Endometriosis is an inflammatory condition. And the way I like to explain it is when your body responds abnormally

to a normal process. You have immune dysfunction as well. So let's think of it as an autoimmune disease and a

chronic inflammatory disease. When you have your period, you bleed out indometrial cells in your menstrual

blood. We're used to that. In everybody, you also have some indometrial cells that will escape out the fallopian

tubes. That's not a big deal. If you take out somebody's appendix while they're on their period, you'll actually see menstrual blood in their abdominal

cavity. In the regular person without endo, your body says, "Oh, she's just on

her period." In the person who has endometriosis, this creates a huge inflammatory response where your body

starts to attack indometrial cells and you get these implants throughout the what's called the peritineal cavity or

the abdominal cavity of indometriallike tissue that gets worse every time your

body sees estrogen which because it's feeding the endometrium just like it would in the uterus and so it gets worse

over time. The more ovulatory cycles you have the disease gets worse. It's so inflammatory that it's not uncommon to

get extensive organ scarring. You get anatomical distortion. These are some of the

toughest surgical cases in addition to managing lifelong health but also

fertility as well. Just obliterate the anatomy like because the infiltration you'll these implants will start growing into other organs

because they'll find new blood supply. They'll steal blood, you know, blood supply from from the bowel from because

all of our pelvic organs are just sitting there on top of each other, the bladder, the bowel, the c, you know, and

so it sounds like it's alive, like it's a cancer or something. Think of it like velcro is what I say almost these little patches of velcro

and they just start sticking together. And that's what inflammation and scarring does throughout your whole body. And what happens here is that

because the primary symptoms of endometriosis is pain. So again, back to

women's pain being taken seriously. That's one of the issues and why the

average time to diagnosis is 7 to 10 years. Truly 17 years in this case from when she had pain.

But the other symptoms do include sometimes also pain with intercourse. Typically though, that is very hard to

ascertain from somebody, but it's usually with certain positions. Deep penetration tends to be what really

stimulates pain. But you also see a lot of GI manifestations that we don't talk about. So if I have somebody who has

painful periods and they say they have irritable bowel syndrome or a lot of vague GI complaints,

that is a really big red flag to me because like you said, these little indometrial implants on the bowel, the

intestine, this high inflammation that's happening irritates your intestine and you get this GI response as well. One of

the hardest things about indometriosis is that it's a surgical diagnosis only. To be honest, we can means

have to do surgery to fully see and diagnose that you have this. It's one of those no meat, no treat, you

know, in in in medicine where you can't make the diagnosis until you have a tissue sample. So meat means you go and

take a biopsy. Okay. See? Okay. So you can suspect it based on imaging.

We're not great at this. And Dr. Crawford, why don't we have a cure? Mhm. Well, because it hasn't been

studied is one of is the primary answer. Uh the secondary answer is that often

the the goals are tough with endo because if estrogen feeds it, we all are going to sit at this table and talk

about how important estrogen is for your body. And a a lot of the treatments that exist for endometriosis take estrogen

away to try to not feed these lesions. And that has a slew of other symptoms and long-term health implications as

well. Truly, we don't even give women

options to try to feel better. They are given birth control pills because, hey, I'm going to stop the ovulatory cycle.

I'm going to you're going to have less what we call unopposed estrogen days. We do have symptomatic relief. Yeah. But we have and that's going to

help hopefully with some of your symptoms. And it can for some women. It doesn't reverse disease. It doesn't cure

it. It doesn't make anything better, but it can slow down the progression any of

these treatments that do halt the ovulatory process, but it severely impacts I mean beyond so many layers of

your your mental your emotional health, your relationships, but your fertility. Stage three or four disease, regardless

of your age, you're going to have a less than a 20% chance of conceiving naturally over the course of your life if you have stage three or four disease.

Every stage is impactful to your fertility because of the inflammation. Once you have anatomical distortion, an

indometrium or cyst inside the ovary, removing that cyst is going to decrease your egg count. That that's going to

have a major implication on your potential. That's why we froze eggs

before we to cyst out so that we could get those eggs, at least some that we could out of the body before we went and

did something that was going to destroy part of the ovarian tissue. What you said, Stephen, is it seems like

indometriosis is alive. And that's a really great analogy because it does just feed into tissue and it's highly

destructive and if it distorts the anatomy, we need a healthy floppy

fallopian tube generally that can swing around and pick up this egg that's floating around our abdominal cavity for

and then you need a place for the egg and sperm to meet which is generally a healthy non-inflamed fallopian tube. So

they're also at increased risk for infertility but ectopic pregnancies. That's where I see them, you know, is

when I was a hospitalist is in the O, you know, emerently from a ruptured

fallopian tube from this, you know, and I go in and I'm making not only she's lost a wanted pregnancy now I and I'm

making the diagnosis of indometriosis at the same time and they are just devastated. I just feel sitting here not

being anywhere within this field thinking wait a minute because I was a cancer nurse first right before I did

this wait a minute there's got to be a cell surface marker that's unique to the endometrium that we could make a

monoconal antibbody against there's got to be a cell surface marker and I will say that there are people now

doing lovely and wonderful research on a cellular level of indometriosis trying to look at the endometrium itself what

cell markers are similar in indometrial implants Can you diagnose this on an endometrial

biopsy in somebody? We haven't seen it get to the point where it needs to, but at least people

are paying attention. So, I do think we might have emergent technology that will change the course of this for people.

Right now, I think awareness is key. And one thing I always say is that especially as a teenager because women

adjust. You accommodate to the world around you. That's one of the things that I think makes women so resilient. I

mean, if you have pain every single month of your life, you are going to convince yourself this is normal for a

degree of time because what other option do you have? Has to get so bad. But when you're a teenager, you don't know that.

And so, if when you are a teen, you would stay home from school, you would not go to the football game or go out to

dinner with friends, that to me has is a huge red flag. But it actually is a very

high predictive marker that you do have indometriosis. So pain out of proportion to being able

to complete your normal life as a teenager is a really big warning flag. I ask every patient about that when we

talk about their periods because 50% of patients with unexplained infertility have indometriosis.

It is so hard to diagnose and underdiagnosed yet impactful to our body.

26 years old. The advice given to her by the NHS was to go back on the pill to

solve for the the pains that she was getting. We certainly have a lot of dismissive doctors and people who don't

take pain seriously, but also a disease that is underfunded and not researched. We do have limited options for how you

can help somebody. And I think we have to acknowledge that both things can be right. Now, getting to the root cause of

your pain is always going to be really important versus just saying here's a birth control pill that should take care

of it. Some women with endometriosis love being on the birth control pill. does highly improve their symptom

profile and it's an important part of their treatment regimen. Other women do not find any benefit from it and it's

really important to have the discussion especially with indometriosis in regards to your family planning goals. Do you

want kids? When is that going to be? What might this look like? Because we know if you have a higher rate of

infertility, a higher rate of needing IVF, do we need to intervene sooner? But

that's going to impact some of the treatment options we're able to give you because some of them do delay ovulation from for a prolonged period of time.

What I find in the patients, you know, when we made the diagnosis was they're forced into making these kind of

life-changing decisions about around their fertility and ability to conceive

before they were ever before their peers were even thinking about it. It's pretty

devastating. It is. We have some pilot data looking at taking some of the nuances of

recovery and looking at how to dampen inflammation. So we have some pilot data

that's showing when women do cold exposure that it dampens inflammation and

improves their symptomology. So I'm always thinking on the outside like what other things can we do to dampen

inflammation in a positive way to improve symptomology. How does that work? So, if we're

thinking about the responses to cold exposure, and we're not talking about ice, we're talking about cold water

exposure. It creates a cascade of immune responses that kind of protects the

body. So, we're reducing inflammation, we're improving parasympathetic, which reduces stress. Mhm.

So, if we're timing it and they know when their period is and they can go,

okay, well, for the next or the 10 to 14 days before my period starts, I'm going to have 10 minutes of cold water

exposure. And over the course of 3 to 4 months, that immune response becomes

learned. So, it reduces symptomology. So, it becomes one of the treatment options that we have for some of our

athletes that have endo and interferes with their training. Mhm. So I mean the cold water exposure is

available there. So that's how we started the pilot study. Um trying someone wanted to do this at

home. 10° C. So what is that about 40? Yeah. It feels really cold but not

an ice bath. Not an ice bath because ice is Ice is not good for Can you get that in the shower?

You you need to This is like cold submersion. Can you do that at a home tub just with turning on the spigot?

You could if you get really cold. Yeah. You might want to add a little bit of ice and let it melt. Okay. But um not ice baths that we see in all

the popular media because that is way too cold for a woman's body. It does the opposite. It's a severe stress and

causes a stress response rather than a parasympathetic calming response that we want.

Okay. Like Stacy said, decreasing inflammation in an inflammatory disease is key to controlling the factors you

can. And much like we talked about inflammation and PCOS, we heard the same word right here with endometriosis.

Chronic inflammatory diseases are the number one thing that we see across the board impacting the population but

especially women. And so these same strategies to work on decreasing your own inflammation

and for endo it's a little different because you can target it for when you expect to have that high inflammatory

burden. But that's really an important part that we don't talk about. I don't see that the NHS talked about an

anti-inflammatory diet or getting more sleep or cold exposure.

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of the questions that came in from the audience was, "How terrible is birth control to female hormones?"

The birth control pill shuts off the brain's desire to send the signal to the

ovary to make hormones. So, it is ethanol estradiol, a synthetic estrogen, and a type of a synthetic progesterine

or progesterone. These work, the brain thinks that you have estrogen and

progesterone present. As we said, that's the ludial phase. And so, your brain says we don't need an egg to grow.

Ovulation starts in the brain. Y, right? So, no FSH comes out and you're not going to get ovulation. So they're very

effective for prevention of ovulation which is makes it a very effective contraceptive option. But as far as hor

hormonal shifts, yeah, your brain's not sending out FSH and LH. Your ovaries are not going to be making estradiol or

progesterone or testosterone. True. And so that is how they are sometimes helpful if you have, you know, uh some

women get hemorrhagic cysts with ovulation. every every time you ovulate, you when you rupture that cyst, you get

a lot of bleeding. The birth control pill can prevent ovulation, therefore prevent some women from being in

terrible pain. If you have PCOS, they're often handed out like candy. One reason is because it will regulate your cycle

so that you don't have these prolonged irregular periods, but also will decrease testosterone levels, which is

sometimes a good side effect of the pill for women who have PCOS, back to a normal level.

Yeah. But if you don't have PCOS or the regular person, a lot of times your

body's tissues are not responding to synthetic estrogen and progesterone the same way it does to natural. I think that's a very important point. So my

niece who competes uh at a national level and she's 14 started suffering

from as she was going through her adolescence her acne got outrageous and she's a 14-year-old girl 13. start at 12

and a half. And of course, you know, she goes to the dermatologist and they're trying some topicals. And then finally,

as you go down the algorithm for how we treat acne, one of the off label uses is

birth control pills will lower the testosterone. Their skin can clear up. So, her father, a little concern, comes to me. Um, her mom passed away. Her

stepmom had passed away. So, he didn't have the mom in the house to, you know, the immediate mom to talk to. And for

the first time, I immediately thought of her athletic performance. Thank you, Dr. Sims and I thought she wants to go to

the Olympics. There's no way I'm going to let her testosterone levels drop. Like, we're going to throw everything

topical at this. And we finally found the right combination. Her skin looks great and she's super happy. But like, the next logical thing was to put this

14-year-old, you know, on a birth control pill to get her acne under control, which is the end result. But

what no one's thinking of is her athletic performance. How is it going to affect her

training years leading and her training years? Like, this is critical for her. 16 is when the next trials are up for her. So that's 2 years

from now. So we were able to get her acne under control, avoid the birth control pill, but that was nothing I'd

ever thought of before. Well, I'm sitting here from a muscularkeeletal standpoint thinking

about the high percentage of women who have endometriosis and PCOS and the

complete soundingly imbalance of natural hormones. Plus,

for a lot of reasons now, girls are not cycling normally.

Mhm. And I'm sitting here terrified for their bones. Yep. 100%.

Because we build bone from 15 to 25. And if we are so inflamed that we're

producing all kinds of inflammatory cytoines IG interlucan 6 and uh C

reactive protein and tumor necrosis factor which halt bone development we

don't have enough estrogen for whatever reason we're going to shut off our testosterone because it makes us feel

better and we're not exercising and we're sitting around. No wonder I have 20 and 30 year olds

with no bone density that are then going to go into pmenopause which we will get

to and lose another 20%. So I was pretty feeling pretty hopeful

that the generation Xers are going to get to the millennials and get to the

whatever they're called after that. It is we're gonna be you're gonna see it get worse before it gets better. Exactly.

That's what I'm sitting here terrified like. Okay. I thought, okay, baby boomers, those women missed out. Xers,

we're doing the best we can. Millennials, but no, cuz now you're

telling me our 15 to 25 year olds are still in the same detriment with muscle

and bone building. We are trying to change the narrative. That's the group we're trying to target

right now. And I do think by educating across the lifespan, we're going to change how those of us who have 11 and

12 year olds what we recommend. I I treat girls in their teen years when

they come to me without their period much differently than a lot of other people do. But this is learned

experience. Instead of just you don't have a period, here's a birth control pill. Say you're not making estrogen and

this is a crucial time for you. Let's give you estrogen. Let's talk about why you're not. what can we do to change it?

And so this discussion is more than just disease state important like PCOS and endometriosis. It's truly important

across the lifespan of a woman. The choices that are being made in her early reproductive timeline is going to impact

her longevity. Can I ask all of you what you would have done differently for ourselves?

Yeah, for yourselves. Obviously, I know several of you have daughters as well, but what would you have done? I wish

everybody could see all of your faces. Oh yeah, I've talked about this before. I mean, I was amenoric until I was 20.

What's amenoric? Didn't have periods. Okay. Because of high stress, high sport, you

know, didn't care, didn't eat well in the whole um mindset of the, you know, ' 90s of calories in, calories out. If

you're thinner, then you'll run better. If you're running better, then you're going to hit different metrics. cuz I

was a runner in high school and then joined the crew team. Same thing. So, if I could go back and talk to my younger

self, I would have been like, "You need to eat, you need to recover, you need to eat, you need to recover." Instead of

the mantra of calories in, calories out, more cardio, lose weight, lose weight, lose weight. Because now I educate

people is you want to take up space, you want to be strong, you want to look at um not the idea of losing something, but

gaining something, gaining that power, gaining that strength, gaining that bone, gaining that muscle, gaining your

period. Those are the things that I'm trying to educate the younger generation cuz that was not impressed upon me as a

younger athlete, which then had a lot of repercussions later in life. Luckily, my

bone density is fine. So, were you on the contraceptive pill? No, you might. Okay.

I was um not an athlete, so mere mortal. And um

uh but it's so you've you've you've been able to take that experience though and apply what you've learned in this this

high int, you know, working with these intense athletes to the to the regular, you know, to people who don't exercise

at that level. And you know, I completely fell under the

the expectation of the aesthetics of it. When I did exercise, I exercised to look

a certain way. And then in my 30s, I exercised for performance. I started running half marathons. I was doing baby

triathlons, really short ones with my girlfriends. It was a social thing and it was super fun. You know, I was running for time. Now I'm exercising for

my old lady body. Yep. You know, I'm exercising to be in a bigger body cuz I know my mother and my grandmother. So,

my grandmother spent the last 10 years of her life in a bed incontinent with dementia and completely frail.

And my mother is on the same course. My mother is 88, fell and broke her hip in January. She just now is walking on a

walk or she's in assisted living facility for Alzheimer's. I want to change that legacy for my

children. I don't want that to be my path and I don't want my children to

have that to be an expectation. So all of the things I would have done

differently was I wanted to be thin. Thin was healthy. That is what I learned in medical

school. The thinner you were up to starvation, you know, up to you want the lowest body mass index possible without

being a little bit too low, you know. And I kind of skirted that line because I stopped eating in medical school due to stress. I would have fed myself. I

would have lifted weights. I would have stopped doing so much cardio because knowing I was chipping away at my bone

density. I was chipping away. I was raising my inflammation levels. I was chipping away at my ability to resist

the Alzheimer's, you know, and dementia that runs in my family. And that's what I'm trying to impress. My girls are 21

and 25. What I'm trying trying to impress on them. But that's the mentality that we grew up

in, right? When you're looking at the supermodels of the '9s and Kate Moss and it was all

heroin chic. Yes, heroin chic, which is the worry now with the GLP1s coming back and the

ballerina body and all the things that we're seeing come back again. And it's it is worrisome.

You know, when I think about I mean, I've already told the world now about having low body fat, maybe being POS and

not knowing it, not ever talking about that, having no periods, but then so there was that in my youth that that I

would have done better, but that it didn't end in my youth. I mean, I went to college, same. I went to grad school,

still same. I went to medical school and in medical school and

four years of medical school, seven years of residency and fellowship. Still didn't eat, still wasn't having periods.

I didn't sleep for about 11 years, whether between call every third night and then I had a baby and then I was

awake for two years cuz she slept with me. That's another discussion. But I

think of all these things that I wish I knew then that I know now. I have the same goal. I have four 30-year-old

daughters and I have a 17-year-old and they are not going to be allowed to hit

a wall like some of us may because we didn't know. And were you on the birth control pill?

You know, intermittently. Uh probably totally in my life about 10 years, but

um not continuously. And Mary, I forgot to ask, were you on the birth control? Yeah, you were off

and on for 20 years. So, polycystic ovarian syndrome that was the treatment. I mean, I learned about

nutrition kind of on the back end. But the life that I had set up for myself

between, you know, medical school, residency, and then going into the field

of OBGYn with limited sleep, you know, working 100hour weeks there. I didn't

have a environment that would have been conducive to be able to manage that disease

with lifestyle and I can look back and say that honestly now

um with without using the crutch of the birth control pill to manage my

symptoms. I was on the birth control pill for probably 15 years continuously. And you

know, we have to give credit where credit's due because I was able to pursue medical training and not worry

about what family building looked like for me, which was really important

because I was not ready to have a child. So, anytime we frame a discussion around birth control, I always want to say it's

not ever going to fit into one bucket of all good or all bad. It's going to be, you know, different stages of life, different things are important. I didn't

stop it soon enough to learn to track my cycle. I didn't recognize cycle abnormalities when I had recurrent

miscarriages. I had a really hard time knowing is this how my cycle's supposed to be or not because I never had the

opportunity to just have periods and see what is my normal. I stopped it and started trying right away and got into a

cycle of having a pregnancy and that would last for a while and then I would lose it. So I really lost the

opportunity to say this is my baseline and oh there might be a problem here or to intervene. I wish id advocated more

when I had my own pregnancy losses. I was told over and over, there's nothing you can do. This is nothing. Just keep

trying. And even as somebody in the field, that felt very dismissive and is a fuel for a lot of what I do now. But

on a personal level, you know, 10 years after having those pregnancy losses, I was diagnosed with celiac disease

because I had osteopenia on a dexa scam. And so I had to explain what that is.

Yeah. So celiac disease is essentially an allergic reaction to gluten. So when I was taking gluten, which is in most of

your carbohydrates or the good stuff like breads and pastas, when I was eating those, it was

causing an inflammatory reaction inside my body, making my gut unhealthy and

kind of creating a baseline level of, let's say, chronic inflammation. And recurrent pregnancy loss can be one

of the signs and symptoms of it in addition to just some other what feel like very generalized symptoms. fatigue,

low energy, headaches, GI distress, WW. Yeah, I was a whiny woman. And when some

of these symptoms finally got to a state where they were getting worse, probably with hormonal change with age, and my

doctor ordered a bone scan, and it came back that I had osteopenia, which is very low density of my bones for my age

and especially at the time, you know, no known medical problems. And so luckily had somebody who was very committed to

not labeling me a WW and saying I think you're not absorbing something correctly to get on this pathway to figure out

that because of this autoimmune disease celiac disease I wasn't my gut was inflamed. I wasn't be able to absorb the

nutrients that I needed. But somebody had to be committed on the other end because these symptoms went on for so long. I just accepted them. I let

them be. But I also am scared because those critical bone building years I was

on the PEL and I used it continuously which means every single day all the time

I you know I know I was chronically inflamed and so now I'm at a stage of my life at 43 saying I've got to try to

catch up before it's too late and that is scary and can you catch up?

Yes. Yes, you can build bone. Um because you know I see all these grass wonder that

you know you kind of yes you go curve but yeah and then it goes down from your wherever you manage to get it

up to. So I'm telling all my friends at the moment thanks to you I'm telling all of them to get their muscle and their bone as high as possible because it's

probably going to fall with age naturally. Well everyone ages. Yeah. Age is the most natural

thing we do from the minute of our birth. But men and women age at different rates, especially

after pmenopause with the the lack of estrogen, we rate we age very

differently from that point on. But your point being made is can we please

maximize our bone density and our muscle mass and everything else frankly

in our youth when we're probably not aware, right? When we're in college and doing all the things kids do, it's the

last thing on our mind. And yet it's the most critical time because you want to start both your bone and your muscle

from the highest possible level. Now, can you through lifestyle and hormones

build bone again? Yes, actually you can. But wouldn't it have been better to start out with the maximum so that the

natural decline doesn't take you into dangerous levels? Right. Mhm. On that point of birth control, what are

you saying to your daughters that wasn't said to you? Are you Because Mel regrets, my girlfriend, she's very open.

She regrets being on the birth control pill for 10 years because she had no idea what it what it was doing to her body. And then obviously when she came

off her cycle, I think she spent like you, Natalie, 2 years trying to figure out what was going on and she didn't

have her period for an extended period of time after she came off. What are you saying to your daughters about the birth control pill that wasn't said to you?

Are you recommending them to use it how you guys used it or I mean, we were started on it so young. I I do see a trend towards not starting

it as young as it was started in our generation and I think that that is important. I see, you know, personally,

my daughter is not quite at that stage yet. So, we haven't had to make these decisions as um they have had to, but I

do think it's cycle awareness is one of the few early signs you have of your body's health as a young woman. And so,

to purposefully never get to know what that is, is a detriment to saying, "I'm aware of what's healthy for me and I

know what's happening in my body." But you guys have had these discussions at different time periods. For my youngest

daughter, we I was worried about uh she was a dancer also. She was teeny tiny. So tiny

even though she had great muscle mass, but she like me wasn't having periods. And so the advice was to put her on

birth control to regulate periods. But I was always uncomfortable with that

because she didn't to be a dancer. She didn't have to be quite as tiny as she was. And so what we have done now is

I've encouraged her to gain a little weight and get a little bit more body fat because I took her off of that. She

only had to gain 5 lbs. I think I said to you, maybe seven and it has more

regulated her and she's having her own periods now. And so I don't know what

she's going to decide. She's going to be 18 soon. And but I think what we should be telling our daughters is all the

information so that they can make an educated decision because I just did

what I was told and I'm a doctor and I and but I'm not an OB so I don't understand the nuances

of what the pill is that it's synthetic that this is how it works this is what

it doesn't do. So I would want to give my daughters all the information so that

they can make an educated decision. So my oldest, the first one coming through, uh wanted it for contraception.

And so when we talk about contraception, it's not just most people automatically think the oral birth control pill, but I

did go through all of the options with her and then sent her to a trusted friend um to let her go and make her own

decision. and she decided to have an an IUD inserted, which I thought was a great choice for her cuz she had normal

regular periods before we did this. There were no issues. And she had it inserted and then within a week she

started having severe cramping, called me into the bathroom. And this is my daughter who has not let me see her

unclothed since she was 7 years old. She's just very private and she's like writhing on the floor. Bless her little

heart. And she had expelled the IUD on her own. She had cramped it out uterus

pushed it out of her body and it was extraordinarily painful and so we basically delivered the IUD on her

bathroom. So do you know what an IUD is? Is not the coil is that's one form of an IUD. She had a

different form but she basically pushed out her own IUD her uterus uterine device. So it's birth control

that is placed inside the uterus and it's shaped like a tea. It is shaped like a most is shaped like

a tea. the UK they use the coil still quite a bit which is copper and so um

there's different there's different options for the IUD some contain progesterine some contain just the

copper and so the way an IUD works is that it creates an inflammatory response in the uterus so that um the cervical

mucus thickens so that when we are fertile in our for fertility window midcycle and jump in if I mess this up

the mucus of the cervix thins to the point where sperm can actually get through most of the month probably 85 to

90% of the month the sperm cannot traverse the cervix you cannot you know so in our fertility window right at

ovulation the cervical mucus thins and then the sperm can transmit so the you the the presence of the IUD creates an

inflammatory environment that will basically is toxic to sperm and thickens the cervical mucus where it becomes a

plug that's how it works works very very well Katherine within a week her uterus

ejected it so she cramped so much that it pushed it through and so that wasn't

an option for her. She wasn't willing to go through that again. So then at that point she had to go through the hormonal

options for for that and she decided to have the implant. So it's progesterone

only implanted in her arm. Quickly we realized she needed some estrogen. So we she supplements estrogen on top of that.

Stephen, I think the contraceptive discussion we have to say that there are options that are highly effective at

preventing pregnancy and at some times in your life that is the number one most important goal and we need to choose a

highly effective option. However, certain some of those options included have downstream impacts that have not

been discussed about. The typical contraceptive discussion says here are some side effects you may have. If you

want to still proceed, let's go for it. We're not talking about long-term implications of these. We're just talking about how you're going to feel,

not exactly what is happening in your body. A lot of these contraceptive options are progesterone only. And so,

you know, by your new favorite graph that you don't see progesterone every single day. So, when you have

progesterone only, it is shifting your hormonal profile. And a lot of women,

this progesterone is so high that it works by also preventing ovulation. Makes it highly effective. But if you're

not ovulating, you're not going to be making those high estrogen levels. And Dr. Haver and I have even talked about

how we wish there was a contraceptive option that had estradiol in it so that

your body could still have some estradi. Estradiol. So this ethanol estradiol is

very different than plain estradiol. They've they've put this estester group on the end which makes it bind to the

estrogen receptor in the brain 300 times more

powerful powerful than regular estradile. Yeah. Which is why it's so effective. you know

why we do it in a micro dose versus estradiol is dosed in milligrams and ethanol estradile is dosed in micrograms

because it is that much more potent. Um so very very different. Now in the UK

and in other places in Europe there is a new form of contraception that has asteratrol which is the fetal estrogen.

So we have four natural estrogens in the body. The ovary produces estradile. That's the one we all know. It it it's

really the biggest bang for our buck. The placenta produces something called estriol. Our fat cells and in the

peripheral tissues, the tissues outside of the ovaries can produce something called estrone. And then we have this

fetal estrogen called eststeratrol, if I'm pronouncing it correctly. And so they've they've compounded they've been

able to formulate that. Um, so it is one of the natural estrogens and they've put it in a birth control pill that is

available in the UK. If you were 18, what choice would you make for contraception? No, studies have proven within a shadow of a

doubt that relying on natural family planning at most ages is not a reliable

form of contraception. So I would not recommend that and relying on condoms. What do you mean by natur relying on

natural family? So you timing your intercourse. Oh okay. So cycle tracking we know that the fertile window is the 5 days before and

the day of ovulation 5 days before 5 days before and then the day of. Sperm can live for 5 days in the female

reproductive tract. The egg lives for 24 hours. So on this graph, where is Yep. So the line right is ovulation and

then the 5 days before. Yeah. Yeah. So in popular culture, you would call that natural family planning.

Okay. Fine. Avoiding intercourse. Abstaining any time in that window. But but if I if I'm trying to get male

pregnant, then I should really be aiming. Yeah. Those are your target days. Yeah. There apps for that you can track. Yeah.

Oh, I've got the app. Yeah. Okay. Oh, he knows. Remember the variability.

He's made download it nine times. There's a few different ways you can do natural family planning to hijack the

discussion for a minute and they have different degrees of effectiveness, but one of the main issues is that they have

very large abstinence windows. So, it's often not very sustainable to say, "Well, we're just not going to have intercourse for 18 days out of the month

or some very long time period, depending on which one, because your cycle's never

perfect. What if you did ovulate sooner? If this is all you're relying on for your prevention of pregnancy, you have

to really assure that you know when that ovulation is happening, it can be an effective way to prevent pregnancy if

your cycles are very regular. But in my brain, I wish that's what you stop the birth control pill at least 6 months

before you want to get pregnant. And then you start learning how to track your cycles and you're using some natural family planning if you're not

quite ready then because the margin of error, oopsies, it didn't work. the

acceptance of well we were going to try to get pregnant soon is usually okay. It's not an effective contraception for

most of the population. We have to factor in when we're looking at, you know, I was trained and taught to only

look at birth control through the lens of contraception, right? We know that they might have some weird bleeding and

maybe a few headaches. And for some a DVT, if they have, you know, deep venus thrombosis, you can have blood clots.

It'll increase your risk, especially if you have a pre-genetic disposition to that. But what we didn't talk about were

mental health, mood, and some of the long downstream libido effects. So,

of of taking, right? And so then I'm looking at it through the lens of, you know, if I'm only looking at on the lens of she

doesn't want to be pregnant younger patient. So you're talking about 18 is less likely to remember to do

something every day. Correct. Okay. So then to take the impetus of remembering to take a pill every day or

change a patch once a week um for the patch option. Then we're looking at

maybe a vaginal ring that she inserts for 3 weeks and removes for one for her period. Pick one. If I had to pick one right

now, if I was if it was available in the US, I think I would go with the

Asteratrol. What's that option? That's the one she's saying is in the UK, a newer option that we don't have. No, it's still a pill. It's still

a pill. Yeah. And it's it's because it it more it looks like so far it's newer that it

has less of the downstream effects. So you're not having that complete suppression, you know, that complete

binding and it's it's, you know, may have and also probably has less risk of

um DVT of blood. I'll jump on this. I do not love

intrauterine device for a patient who is 18 for a multitude of reasons. Now, I'm going to preface this to say it is an

highly effective contraceptive choice. It's one of the most effective ones that we have. And so there are certainly

circumstances where that is the right thing to do. We've had IUDs in practice for a really long time. For the majority

of this, we were only placing them in women after they had given birth at least once because of their size and

being able to pass them through the cervix. Now we have different options and we are offering them to women younger, which is wonderful. However,

when we're putting IUDs in the uterus of women who are really young, sometimes the progesterone dose in them is so high

that it is preventing ovulation. And we are seeing young women who are not ovulating and they are not making

estrogen therefore and they don't even really realize it because that's not disclosed as one of the main

mechanisms of a progesterone IUD because it doesn't happen in enough people to effectively prevent conception that way.

It works through the inflammation, the cervical mucus changes. And why does that matter? Because if you

are not ovulating and you're not making estrogen, you are going to have low libido, low energy, you're not going to

build your bones during critical years. Let's say let's say the IUD lasts 5 to seven years. You're 18 to 25. These are

some of the most critical years in your mental health, your bone health, your cardiac health. And being low estrogen

during that time is going to set you up on a different risk trajectory for your entire life.

And the worst thing here about the progesterone IUD is that because of the progesterone, which will thin the

lining, many women just say, "I don't have my period because my lining is so

thin." And that's a side effect of the IUD. If that same woman was not

ovulating, and came to me and said, "I haven't had a period in 7 years, and I knew she was low estrogen and not

ovulating." We're highly concerned about her health. But because she has an IUD,

what happens? Well, that's a side effect of IUD. No big deal. So, we're missing the moment to

understand where are some of these symptoms just side effect of the IUD or

are they having a much bigger role in what's going to happen to that woman's long-term trajectory for being low

estrogen during crucial years? And I'll say this, Stephen, I'm very biased, right? I'm a fertility doctor. I see

patients who have trouble getting pregnant. That is a narrow subset. That is not the majority of women who have

IUDs. So, what would you suggest if you had to pick one contraceptive? Vasectomy.

Yeah, I would still do I would still do the pill right now. The pill or the vaginal ring? You know, I think they are both depending on somebody's personal

preference. I just think that it's really important if you're using the birth control pill. I do think it's

important to give your brain a break from the pill at times and even if you're cycling it monthly, you there's

options now. I took the pill, an active pill. every single day for for years, a

decade probably, meaning suppressed my brain completely for that long. Now,

your brain sends out hormone signals that impact your entire body, right? So, we already talked about the hormones and

how it's this beautifully conducted symphony. But if you even if you're going to take the pill at that young

age, I would say take it so that you have the seven days of not t not taking a pill. let your brain have a moment of

release from the suppression and then take it again. That's still a very effective way to use the pill. But

because women don't love having periods, we've offered these other options which are not wrong, but they just have a

bigger consequence downstream than we're talking about. But the pill is very short acting. It only has a

halfife of 28 hours, meaning it is out of your body very quickly. So, you do want to stop the pill and see what is

happening and track your cycles. That is something nice about it versus an implant or an IUD. That is

fit and forget. The fit and forgets that people like set it and forget. Yeah. Yeah. The question that came in from the

10,00 women we spoke to in the diarrhea audience was, is there any way to control hormonal mood swings during the

luil phase of the menstrual cycle, which I now know is the second phase of the menstrual cycle. Stephen, you've learned so much. Yes,

that's great. I love that. In the ludal phase, we do tend to see more mood changes and physical changes. And a lot

of this is because we have an increase in estrogen and progesterone and then a

decrease in both of these hormones. And what we find is that some women are simply more sensitive to these changes.

They feel them quite profoundly. And there's even something called PMDD, premenstrual dysphoric disorder, which

is when those hormones are dropping. You get these terrible mood swings, this terrible depression and anxiety in

addition to physical changes with terrible fatigue. You just feel like you can't accomplish any of your tasks,

insomnia, quite similar to a lot of the things that we talk about anytime we talk about a low estrogen state,

right? Like po we see it in um postpartum depression. It's a very similar and in the permenopause

transition, we have a 40% increase in mental health changes. And we know this

because women tell us and we believe them. But what's happening is that our neurotransmitters, especially GABA,

serotonin, and dopamine levels are highly tied to what our hormone levels are doing.

Yeah. So is this is the mood swing or is the is the

what's the right term to describe a mood when someone doesn't feel great? Dysphoria. Dysphoria

is the deoria mood after the period or before it. It's often it's before. So the estrogen

is dropping before and it stays low through. So what happens is about the week before your period and then the

week we'll say of your period you are estrogen low. The rise of estrogen from that next egg being recruited is

actually what stops you from bleeding and helps you start to feel better. Because of this, a lot of people will

throw a birth control pill at this situation because they will say, "I will give you constant hormone levels every

day and now you will not have these PMDD symptoms anymore." However, a lot of

women don't want to be on the pill for a variety of the different reasons we've talked about. They just feel bad, let's say, this week or this 7 to 10 day

interval. They don't want to suppress ovulation. I find that a lowd dose estrogen in the ludial phase can be very

effective in targeting after ovulation. I'm going to take some estrogen helping alleviate these symptoms without

interfering with ovulatory function. But I was trained to give them an SSRI for

those 7 to 10 days. An anti-depressant pill. Yes, an anti-depressant only for those two weeks. Saraphim was that the brand

name of it. And it does tend to help. But what no one taught me and what clinical experience has taught me and

talking to all these other smart people is a lowd dose estrogen like

treating the root cause treating the root cause. Just just give her estrogen back during that time period and she gets remarkably better.

In some of the nutrition research finding that low iron and low vitamin D are huge contributors to it. So there's

that research to investigate too, which is interesting because there are some women also who don't want to go on SSRI

or estradile. So, you know, the endocrine society does not recommend routine testing of vitamin

D. It's crazy. I I just think it's insane. Yeah. With my partner, I should anticipate that her mood might drop in the leadup

to her having her period. Mhm. It's very common. And then after her period, it would might recover. And whether or not that

becomes clinically significant, whether or not it's life disruptive for her rather than she just has a little bit of a low mood, most women can tolerate

that. But for those who can't and that it is disrupting their day-to-day activities and how they feel about the

world, we have options. Yeah. Cuz I'm trying to understand I want to understand her better. So I'm looking at

this little graph here which says the brain during the menstrual cycle. So the menstrual cycle starts when her period

starts by convention. Yes. That's what we say. Day one is the first day you start bleeding. Okay. And so what is she going to go

through for the next 29 days? And how might I support her better through that journey? Like I want to understand what's going

on in her brain. Her brain starts by s from a reproductive hormone level. The brain starts by sending out FSH, follical

stimulating hormone, which is going to get her ovary to start growing an egg which lives inside a follicle and making

estrogen. And that rise in estrogen as it's growing will stop her from bleeding. So the beginning that cycle

day one, the bleeding that she's experiencing or her period is because she didn't get pregnant in the month

before. So it's getting rid of that indometrial lining, cleaning the slate. She's estrogen and progesterone low

during that time period. And then once her bleeding stops, it's because an egg has been chosen. Estrogen is then going

to rise until it gets to that peak level. During that time, she's going to feel her best for most women.

So is that the first 14 days? So the week by convention if you had a 28 day cycle which only about 13% of women

actually do but all of these graphs if you look at usually use 28 days because it's easy to go week by week

and that's the lunar calendar. Yeah 28 days. We see that but we have to acknowledge that most women don't have a 28 day

cycle. So but it is roughly the first two weeks for most women to get up to

that ovulatory time period. So the time from I have started bleeding until I am now ovulating, that is all considered

the follicular phase. And on this little image that I have in front of me here, it says in those first

14 days, she's going to have better spatial skills and be more anxious. So once you get to your estrogen

dominant, so you have a lot of estrogen and you don't have progesterone, most women can are have increased

concentration. They have more focus. They actually can sleep better. They have higher libido. you feel like your

performance even for athletes performance tends to be improved aggression concentration more yeah

during what we call the late follicular phase so that means the time period when you're really making that estrogen let's

call it days 7 to 14 for ease so I'm now done bleeding a follicle is growing

meaning an egg is making enough estrogen to stop that bleeding I've not yet ovulated and seen progesterone this is

where we typically have our best performance overall from how our body is functioning

and then From day 14 onwards, I'm she's going to be calmer.

Well, progesterone slows your body's metabolism down. It It's preparing you for that pregnancy. Calmer is a nice way

to put it, but essentially, your metabolic rate is going to change. Your body's going to shift how it functions.

Many women actually have fatigue. They're hungry. Specifically in the brain, progesterone levels as they rise,

we see an increase in GABA, which is a neurotransmitter, one of our brain hormone, one of our brain, you know,

hormones that talks, you know, jumps between one one neuron to the other. And that is more of a calming hormone. So

women tend to we see sleep changes more. You see deeper sleep, longer sleep in

that ludial phase. She's and on this it says she's going to have she's going to be horny for day 14.

I don't know how else to say it. Because she has an egg available because that's that peak estrogen. That estrogen level of 200 pograms is

heightening everything. To have peak libido when an egg is released, the body is made that way on purpose.

This is a bit off script, but my girlfriend always talks about her HRV

being very different. And so she she has really great HRV scores and then once

every month for a period of time they're terrible and she can't explain it. So

this is where wearables come into play. Yeah. So wearables are not designed to capture women's physiology. So what happens

after ovulation is your respiratory rate goes up, your resting heart rate goes up, and your HRV plummets. So on the

wearables, most women about 5 days before their periods start will never be

in the clear, so to speak. They will never look recovered. They will never look like they can take on a lot of

stress. They're not stress resilient because of the way the algorithms are reading this change that is natural that

is produced by progesterone to alter our respiratory rate and our heart rate. It

doesn't mean that she's not stress resilient is what the wearable is saying. Ah cuz she came downstairs and she said,

"Oh god, my recovery is so bad." And then I think a couple of days later, a

little while later, she had a period. I'm not sure. I can't remember the time frames, but she came downstairs and she was like shocked that she had done

everything right, but her recovery on on her wearable said that she was in terrible state.

This is why we do not let athletes use wearables leading up to a peak event

because they feed into what the wearable respond or telling them and it's not

true data with regards to how their body can actually perform. So wearables data

masters then need to segate segregate populations and make new norms for women

and maybe new norms for different fitness levels of women. Exactly. I've always been pushing for

the past five or six years interacting with wearable companies is like if you want to capture it well then you need to

be able to compare follicular to follicular and ludial to ludal. What does that mean? So comparing

like we know your HIV is going to be different in your follicular phase. This is not a bad thing.

People could could theoretically do that on their wearables and look at the previous month and see the the level you're at then theoretically. Obviously

the wearable companies could do a lot more here to to definitely helpful but no you then it comes back again on the woman trying to

understand and interpret the data herself which can be a little bit problematic because there's so many

women out there like my wearable told me that I'm in the red I can't do anything today when in fact physically and

psychologically they can do what they set out to do. It's just now they have this little seed saying that no, you

can't do it because of an improper algorithm on their wearable.

Probably a good time to disclose that I'm an investor in push. Okay.

Yeah, I will send this to them. Please. Yeah. You wear Do you wear any devices to track your health data?

I wear I wear a CGM and a Whoop. Just give me a minute of your time and

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close off on the subject of fertility because it was um heavily asked by our audience and I I guess I'm well placed

to ask some of these questions because I'm in that journey myself of trying to have a child at the moment. Natalie, you

have five fertility non-negotiables that you talk about. I do and I think it's really important

to think about for too long we've been told, you know, your fertility is luck. It's good luck

if you get pregnant. It's bad luck if it's not. And that's this narrative that gets propagated. And fertility is

certainly not fair. Meaning people will have infertility and do everything right. But there are things that we do

that will inherently also harm our fertility and our hormonal health and make it harder to get pregnant. And

that's even when we are doing treatments. So a lot of times people say, "I'm doing IVF so I don't need to

worry about these non-negotiables." And that's also not true. meaning things that we need to do. We need to, as we've

all said, get more sleep. That's going to be number one. We need to actively work to decrease stress. That is not a

I'm just going to live a stress-free life. But all these things I'm going to not take call. I'm going to set some boundaries and not have late meetings.

I'm going to see morning light. I'm going to take a walk outside. We live in a stressful world and chronic stress

itself can impact your fertility, your natural fertility, and IVF success rates. We're going to work on exercise

to build muscle and try to improve our muscular health since it's part of our

metabolism. We're going to eat an anti-inflammatory diet. That's definitely key, high in fiber. And we're

going to look at the world around us and work on pulling toxins out of our world that we know we haven't even entered the

discussion about how environmental toxins is harming our body, our hormonal health, our fertility, our ovaries, our

organs. And so these are all things that we make active choices on that we have to start paying attention to and kind of

changing. We'll go into detail in the lifestyle factors and the environmental toxins um

in our second episode together. I I've always been quite shocked by this graph because it's quite um quite significant. This is just showing

the um egg count by age. Slide that into that direction. um what do men and women

need to understand about egg counts in order to make better family planning and fertility decisions? Okay. Well, I've asked you this last

time. So, Stephen, how many sperm do you make a second?

Millions. You make 1500 a second. You mean you make millions every day? Is okay. But

still, you still you make a ton of sperm. You make sperm every single day. You have germ cells that create sperm. Women are born with all the eggs you're

ever going to have. And yes, my favorite vault analogy. So, I like to imagine that this is a vault inside your ovary

that is storing all of your eggs. And so, we'll use this cup with all of the beads as that analogy. And every single

month, since before you are born, eggs come out of this vault. And what happens is that when the vault is more full,

more eggs come out every month. And as the vault starts to get emptier, fewer come out. And this means that we lose

the majority of our eggs, you can see the line, well before our reproductive years even start. So you lose the most

before you're born. So from being a 5-month baby to birth, your egg count goes from 6 to 7 million to 1 to 2

million. Millions of eggs lost before you're even born. From birth to puberty, let's say

you go from 1 to 2 million to half a million to simplify numbers. So, the second biggest drop before you're ever

ovulating, before you ever have a chance to get pregnant, and then you only ovulate around 400 eggs over the course

of your reproductive lifespan, as that egg count starts to drop over time, the

other really, really big important factor is that our eggs have been in our body our whole life. Two different

things are happening at the same time. One is that our chromosomes start to leave their perfect position. They

absorb the wear and tear of years. So we see more chromosome abnormalities as we get older. It's why it's harder to get

pregnant and why we see an increase in miscarriage as we age. But also concurrently our metabolic health is

poor as we are older too. And mitochondrial function in eggs. The metabolic capacity becomes less capable.

And so we see that it's harder to get pregnant not because women are running out of eggs but because the quality of

the eggs declines. But everybody will run out of eggs. You'll have a period of time where you have a very low egg

count. We call it diminished ovarian reserve in the fertility world. We call it perry menopause more globally. And

this this is two words to describe the same thing. As your egg count starts to get very low, you start to have an

unpredictable response to your ovary and your brain is trying to compensate for that. And so you see various hormone

changes, but these start before you might recognize even menstrual cycle changes. But everybody will run out of

eggs. Every woman will. your ovaries will go into what we call ovarian failure and no longer respond to

hormonal signals from the brain or artificial signals that we give. Meaning, I will see older women come in

and think that I have magic medicines with IVF that can still help them get pregnant, but I can only get the eggs

outside the vault to grow in IVF. And so, shouldn't we then be freezing our eggs?

You're right. As a society, if we are purposely delaying childbearing, we know that it gets harder to get pregnant with

age. And if having kids is a life goal, putting eggs into the freezer earlier is

a way to save that opportunity. It's not an insurance plan. It's not a guarantee,

but it is a smart game plan, especially as we are waiting longer. Because even

with IVF, we can't always overcome age related infertility if we have fewer eggs and more genetic abnormalities. The

technology helps us identify healthy eggs, helps us have more eggs, able to grow in a certain month and take them

out and test embryos in a lab, but I'm working with the eggs and sperm that you're giving me. Meaning, if there's

not many of them, if there's a lot of chromosomeal damage, if there's a lot of mitochondrial dysfunction, if the sperm

quality is not great, that doesn't mean we're going to be able to have success. So, what you're doing on a daily basis

to impact egg and sperm quality is still crucial. But egg freezing has gotten a

lot of bad rap. It's still a new technology. It's only been around about 10 years off experimental purposes.

Meaning that women who froze their egg 10 years ago, you know, they have much poorer egg survival rates. They were

older at the time. Their experience is very different than the modern woman who is freezing her eggs now, maybe in her

upper 20s or early 30s. What is the optimal age? If you are want to have a child as a life goal and

you're not ready to conceive by age 32, that is when there's a clear delineation

that it makes smarter financial sense as well as likelihood sense. The short

answer like my daughter will freeze her eggs in her 20s. The younger you are, the more eggs that you have. If she

says, "I want to have kids as a life goal," then that will be something that we will do in order to help her keep

that because there's so many other variables which impact your ability to get pregnant or your egg count.

Endometriosis decreases your egg count, right? People will develop an ovarian cyst and they'll have

surgery, surgery, they'll have a twisting of their ovary and maybe they'll lose an ovary, smoking, chemo, radiation,

smoking, marijuana, any abdominal surgery. So many things can impact your your eggs because you only have this

group. You're born with them. So we we plan for life goals differently. And

we've never really talked about our fertility life goals until more recently. Meaning when we went

professional career, right? We knew what we had to do to get into medical school, to get into residency, to get your PhD, you had this list of things and you set

goals and you worked to achieve them. But I always wanted to be a mom. Yet, I already told you I took a birth control

pill every single day and I didn't even think about it until that moment was in front of me. And that's the part of the

discussion that we do have to start to have earlier is if this is a life goal for you, what do we need to do?

Understand our body better, our fertility better, and maybe that does include freezing eggs because it does give many women an opportunity that time

would eliminate. I had a conversation with you Natalie on

the podcast but then many other women over the course of the last two to three years and one of the things that I learned from that was that we as you say

we don't family plan and then we have to deal with the consequences of not family planning. So, as an interviewer, when I do life story episodes, I go through a

woman's life story. And obviously, the women that's sitting in front of me are typically high performers, high achievers in some capacity. And then we

arrive at the end of the conversation when we talk about family and kids and all those kinds of things. And there's

often a lot of tears. And it was in those conversations sitting here with several women that were on the show.

What was the straw that broke the camel's back? It was the UFC fighter Ronda Rousey. It just so happened that

when I interviewed her, she had just found out that her seventh round of IVF

had failed. And so she was very, very emotional. I left that interview and had a conversation with my girlfriend. I was

like, "Listen, I've I've seen too many of um too many women over the age of 35,

maybe sort of under the age of 50, but really under the age of 45 in tears in front of me. I think we should have a

conversation about this. Should we freeze our eggs?" I mean, me and my partner are both 33 now. And um at first

I don't know, maybe it was the way I worded it. She was offended.

She was like, "You don't want to have a baby with me?" It was like Yeah. It was like, "You don't want to have sex with me?" Like I

like didn't word it well. Like I didn't I didn't really think I didn't really think about the emotions surrounding it. I think that was really what it You were trying to make a pragmatic

decision. Yeah. I was as men often do. Like I was just like we should free but I didn't think about what that meant. And there's this this prevailing narrative in

society that if something's not quote unquote natural, then it's not good.

And that IVF or egg freezing is not natural. And that like torments people's brains

because they want to live a natural life even though they're in like [ __ ] planes and on on iPhones. We want this one area of our life to be

natural. And after honestly five minutes of that conversation,

I think the framing that m flipped her mood was that wouldn't we want to give ourselves the option,

right? And it's actually about having options. But I wanted to throw that out there because, you know, I don't think people family plan. I think as you said, we

focus on our careers, then we pop up at 35, 36, 37 and assume that we can.

Mhm. But that is not the case. Yeah. Especially if you live a healthy life, you you think, "Oh, this will be easy for me." or if you're a high

achiever and you've achieved other things, many women are really taken

aback by not being able to achieve this or not having control over infertility

and what is a natural process to run out of eggs and to go into menopause. If you

are lucky to live long enough, this is going to happen. I got my diagnosis of

PCOS in medical school before I was ready to start, you know, family planning. And I knew I was probably

going to struggle. And so it took us about 3 years to successfully conceive

the first time. And you can't even though I'm working in the business, you know, I'm running between

patients to go and have another ultrasound or go get a shot or go do all the things that it took, you know, you

you can't remove the emotion from it. And I can't tell you how many times I cried. And of course, all of my

co-residents, my four best friends, all got pregnant in succession, our poor chief residents, and with no trouble,

you know, and even like crying to my mother about the struggles I was having, she's like, I just I got pregnant eight

times with no trouble, you know, and then my first pregnancy resulted in a miscarriage and, you know, in the middle

of work and all my friends were there and they were cheering. They were so excited I was finally pregnant and then we lost the baby and you know and having

to like push through and work through it's like it was yesterday like you know I have two healthy kids thank God and

you know we were never after those two we tried again we were never able to get pregnant again which you know I had two kids and put a bow on it and we're done

but it is impossible to remove the emotion because

you because in the mindset it's luck or it's something we did

we caused this and it's I you know as a

high performing you know someone who's like you check all the boxes and you make all the good grades and you do everything right and this is the one

thing that suddenly you didn't think much about and then it becomes everything

when that ch that that becomes hard or it's taken away from you but I think women assume that it's our burden

because we assume that if we can't conceive it's just us or something But I

think I heard you say this, the the it's a two-way street and and the issue is

not always the woman. A high percentage of the time it's her partner. And so I don't think we absorb that information

upfront either until we start investigating it. But I'm in awe of this story that four of your residents got

pregnant immediately because in orthopedics that does not happen. Mhm. Every orthopedic surgeon in my

generation that I know if we got pregnant we miscarried and maybe that

was lifestyle and maybe that was not eating for 40 hours. Maybe it's all the radiation that we undertake. I think

it's better now for the younger generation and we as the I'm not that old but I am older than the current

residents. Um, we encourage all of them. If you are not partnered and wanting to

have a child now, then please consider freezing your eggs if that's a goal because we can't predict our futures and

our residencies extend into our 40s. Well, I love that you're helping facilitate that discussion because that

certainly wasn't the culture back when we were in training. I am one of the ones who sat here and cried in front of Steven myself when talking about my own

pregnancy loss journey just because you know I see it every day you know and I tell patients every day news that they

do not want to hear 50% of infertility is due to male factor 50% is due to female factors one of the