Ep. 211 – Addressing the Root Cause of Hormonal Imbalances with Dr. Sara Gottfried

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Dr. Sara Gottfried

Today, I have the privilege of connecting with Dr. Sara Gottfried! Dr. Sara is a board-certified physician who graduated from Harvard and MIT. She practices evidence-based integrative, precision, and functional medicine. She is a Clinical Assistant Professor in the Department of Integrative Medicine and Nutritional Sciences at Thomas Jefferson University and Director of Precision Medicine at the Marcus Institute of Integrative Health. She has written four New York Times bestselling books, including her latest book called WOMEN, FOOD, AND HORMONES. 

Dr. Sara is one of my favorite doctors in integrative medicine and GYN! In this episode, we dive into the infodemic, how stress impacts hormones, the impact of age-related changes on hormonal regulation, alcohol, and gender differences with ketogenic lifestyles. We discuss some of the lesser-known hormones, including growth hormone, and how to support it properly. We touch on disordered eating, how trauma influences our relationship with food, epigenetics, and the role of a lifetime relationship with food. We also look at methylation, glutathione, detox reactions, supporting physical detoxification, and our toxic diet culture.

I hope you benefit as much from this episode as I did! 


  • Dr. Sara explains what the infodemic is and discusses the impact it has had on how she communicates with her patients. 
  • What happens to our hormones as we age?
  • The impact of stress on hormone regulation.
  • Dr. Sara busts the myth that testosterone is a male hormone and discusses what testosterone means for women.
  • How does alcohol consumption impact women’s hormones?
  • Why do men tend to have an easier time with the ketogenic diet than women?
  • The dramatic changes that occur in women’s bodies as they transition from perimenopause to menopause.
  • Looking at the interrelationship between trauma, stress, and autoimmunity.
  • The changes that occur with growth hormones as we age.
  • How trauma affects the genes.
  • How disordered eating impacts metabolism.
  • How to support physical detoxification naturally, without going to extremes.
  • How to address weight-loss plateaus.


Connect with Dr. Sara Gottfried

Dr. Sara’s books are available at all bookstores.


Connect with Cynthia Thurlow

“Trauma can start to manifest more hormonal changes- especially in times of transition, like pregnancy, postpartum, perimenopause, and menopause.”

– Dr. Sara Gottfried


Cynthia: Welcome to Everyday Wellness Podcast. I’m your host, Nurse Practitioner Cynthia Thurlow. This podcast is designed to educate, empower, and inspire you to achieve your health and wellness goals. My goal and intent are to provide you with the best content and conversations from leaders in the health and wellness industry each week and impact over a million lives.


Today, I had the distinct honor of connecting with Dr. Sara Gottfried, who is a board-certified physician who graduated from Harvard and MIT. She practices evidence based precision and functional medicine. She is a clinical assistant professor in Department of Integrative Med and Nutritional Sciences at Thomas Jefferson University and the Director of Precision Medical at the Marcus Institute of Integrative Health. She is also the author of four New York Times bestselling books including her latest book called Women, Food, and Hormones. She is one of my favorite doctors in the integrative medicine, GYN space, and it really was an honor and a privilege to connect with her. We dove deep into the infodemic, the role of stress and hormones, how age-related changes impact our hormonal regulation throughout our 20s, 30s, 40s, 50s, and beyond, the role of alcohol, gender differences with ketogenic lifestyles and what accounts for differences in physiology. We also spoke about some of the lesser-known hormones like growth hormone and how to properly support this. We touched on disordered eating and how trauma influences our relationship with food, as well as epigenetics and the role of a lifetime relationship with food, methylation, glutathione, detox reactions, how to support detoxification in the body, and our toxic diet culture. I hope you will find this conversation as beneficial as I did and definitely check out her new book. 


Well, I’m delighted and excited to have you joining us this morning. Thank you so much for carving time out of your busy schedule to join the Everyday Wellness Podcast.


Sara: My pleasure. Happy to be here with you, Cynthia.


Cynthia: Well, in your newest book, you used a term that I had never heard before, but it was a term that I think is completely and utterly appropriate. We’re in a time where we have information overload and you refer to this as the infodemic. And so, with the rise of social media with this accessibility of information, how as a clinician have you had to navigate things differently when you’re talking to your patients. Because as a GYN, you’re helping to educate women about their bodies and what they will be anticipating throughout different life stages. But this word infodemic really stood out to me as a term that I had not yet used, but now, thought to myself, “Gosh, it’s so perfect,” especially with what’s gone on the last two years.


Sara: For sure. I would say that infodemic is a combination of a number of different factors. It’s the access that we have to tremendous amounts of information. But a lot of it is delivered to us in a way that’s not filtered like it had been in the past. And so, that combined with polarity and just how polarized in particular the United States is. It’s just led to these extremes of thought and whether you’re talking about COVID-19, or how to balance your hormones, or how best to intermittently fast. What happens is that so many of our people, our tribe are just confused. They get told so many different things and then they’re left to try to make sense of, “Okay, what works for my body?” They’re not always taught or held by the hand and guided through that process. Yeah, I would say, the last two and a half years in particular has really led to more confusion, more polarization in some ways, more hunger for people like you, Cynthia, for people who are able to parse the data in a way that makes common sense, but also is effective and shows up an actionable next step, but also, next steps that make a difference that really have an impact.


Cynthia: I think it’s really important because as a middle-aged woman myself, I always like to start the conversation and say that even with all of the training that I had, there were changes and net impact on hormones in my wellbeing and the way I viewed the world that I didn’t know anything about. It’s only looking at things retrospectively that I can now acknowledge the net impact of things like stress as a really good example. There’s no one listening that has not had more stress in their lives over the last two, two and a half years. The net impact on our hormones is so significant. We’ve assumed what we got away with in our 20s and 30s that we can weather that throughout our lifetime. I remind women that we have to be exquisitely sensitive to the amount of stress that we are experiencing whether it’s emotional stress, physical stress, etc. I can’t exercise as an example the way I did in my 20s and 30s as a 50-year-old woman. That’s not necessarily a bad thing. I don’t even think I want to exercise that way. 


But I think it’s important to maybe think about how women can have the information about the net impact of stress on our hormones and how that has this downstream effect on everything else. I don’t think I had a healthy enough respect for the endocrine system until now or probably, until I hit perimenopause. Let’s talk a little bit about what happens to our hormones as we are starting to get older. In your book, you do a beautiful job talking about age-related changes in our 20s, in our 30s, in our 40s and 50s, but I was surprised that we start losing hormones in our 20s and I think for a lot of the listeners understanding what starting to change physiologically in our bodies makes a lot of sense. It’s why my teenage boys can do things and seem to weather things very easily and effortlessly versus my husband and I who go to bed now earlier than they do. So, let’s start the conversation there.


Sara: Well, you’ve raised so many important points. Let me say first that I’m still board-certified as obstetrician gynecologist, but I turned left many years ago. When I started doing integrative and functional medicine, I started to really take on the literature of men as well. And now, I’m the Director of Precision Medicine at Thomas Jefferson University, where I see a lot of executives, male and female and I want to be gender inclusive here as well. Yeah, when I was in my 20s and 30s, I had this distant thought of menopause and perimenopause as this cliff that you fall off of. I thought, “Ah, I don’t have to worry about that until I’m after 50.” But the truth is, there’s all these subtle changes that occur much sooner than that. As you described, starting in your 20s and it speaks to one of those major differences that I think is important between the mainstream medicine that you and I were taught and then this more functional root cause based integrative precision medicine, whatever you want to call it, that looks at things like, “Well, how about testosterone and its precursor DHEA? What happens with that? Does that also fall off a cliff when you turn 51 or are there changes that happen sooner?” 


As I started to look at this, mostly because I was a hot mess in my 30s. I had a couple of babies and I was just like, “Okay, why does it feel like I’m pushing a rock up the hill all the time?” When I started to look this, I realized, you make choices in your 20s that determine whether your hormones have those slow, gentle decline or a much more precipitous decline, so that includes how much sugar you consume, how much refined carbohydrates, how much stress you perceive. It’s not so much how much you have in your life, but what you perceive, all of those things can accelerate. The loss of hormones such as DHEA and testosterone to the tune of 1% per year starting around age 28 or if you’re doing those things that I was doing like eating sugar. I was a food addict, I was so stressed, I was losing testosterone and DHEA about 2% per year. That may not seem much, but after 10 years, that’s a 20% decline. After 20 years, that’s a 40% decline. So, it’s a pretty big loss.


Cynthia: It’s interesting, because I think many women are perhaps not even aware of the fact that we have– our most potent hormone really is testosterone. We don’t have as much of it, but it’s so much more potent in our bodies than it is for men. The interrelationship, the intricacies between our perceived reality and our brain takes in information and communicates to these glands or these hormones. One of the most common things that I see for women, especially middle aged is, they’re working with someone and they’re given pellets. I’m going to use that as a starting point. I will oftentimes talk to them, you realize that the most common reason why your testosterone level is probably low or suboptimal might be a lot of the stress that you have going on in your life or it could be because of insulin resistance. We know most, if not all, Americans right now are not metabolically flexible. It’s understanding that the traditional allopathic model is really looking at things as we’re treating symptoms, the lab is low, let’s provide the hormone that will fix things versus through a functional or integrative lens, looking at things and saying, “What is contributing to why this hormone is low?” And so, there have been instances when I’m talking to a woman and I’ll say, “Well, it’s probably a lot of stress. It’s the lack of sleep, those exercises you’re doing, you’ve got a very demanding job, you’ve got very young children,” and they just start to understand that stress is so hugely impactful on our health and the way that our hormones are properly regulated or dysregulated.


Sara: Yeah. This is one of the things that makes me crazy in the so-called bioidentical hormone replacement field because what happens is that if you take the stand of just topping off hormones, “Oh, this woman’s low in DHEA. She’s low in testosterone, she’s slow in estradiol, she’s low in progesterone, let’s just give her all of those.” You missed that opportunity to address those root causes that can often allow you to resolve symptoms, sometimes without the use of hormone therapy. But if you end up on hormones, often, it allows you to meet those hormones in the middle, so that you don’t need the same dose, you may not need the same duration. With pellets, we might as well take that on since that’s the elephant in the room here. I’m not a huge fan of pellets. I think they can be helpful when someone’s got a really stable dose of a particular hormone, usually, estradiol or testosterone. But what we know is that when you compare it to other forms of bioidentical hormones, there’s much more in the way of side effects. I know some people who do pellets are going to get up in arms listening to this, but there’s research to show this. 


In my medical practice, I’ve got clinicians that I refer to who do pellets, and they swear by them, and so to their patients. There’s certainly a time and a place for them. But as you were intimating, if you take someone who’s got a high cortisol load, which was my story when I was in my 30s, what happens is, you just add testosterone to the system. You’re not really resolving a lot of those downstream effects like the loss of metabolic flexibility issues with insulin resistance. The things that drive you to crave sugar, to crave refined carbohydrates, so a lot of those women that get the pellets of testosterone often find that it’s not the panacea that they had hoped for. We really have to have this broader context to look at it and of course this is not just an issue for women. Men, because they’ve got 10 times as much testosterone as women, they really notice it when there’s a decline. I work with a lot of professional athletes. During the pandemic, I worked with a lot of NBA players. When those NBA players were in the bubble and they were isolated from their family, and friends, and they just had their teammates, their testosterone levels declined significantly. That’s an example of what happens when you’re under a stress. Even with these professional athletes that you think of as the poster children or the poster men of high testosterone. 


You also made another important point which is, even though, we’ve got less testosterone than men, it’s still the most abundant hormone that we make. If you get a blood panel and I’m a big fan of doing blood panels, looking initially at your hormones, and then I like to look at dried urine and metabolomics. But if you look at a panel, and you look at the level of testosterone that you have, and you look at the level of estradiol, the level of progesterone, the level of IGF-1, which is a proxy for growth hormone, what you’ll find is that testosterone is the most abundant. What that means for women is that we are exquisitely sensitive to it. It is so important for so many things that we do in our lives, whether that’s being an entrepreneur, or being a mother, or mothering a cause. It’s so essential to that sense of agency to confidence, to risk taking that’s been proven in MBA students. We know, of course, that it’s involved in many things like sex drive, and muscle mass, body fat composition, but I think this piece about it being a so-called male hormone, we got to bust that myth right here at the beginning. [chuckles] Very important. 


Cynthia: No, I agree. For a lot of women, they don’t even realize their testosterone is suboptimal until they start having other downstream effects. Now, before we walk away from the stress piece, one thing that I think is really important and I’m sure you probably have seen this with your own patient population, but during the last two years, there’s been so much more alcohol consumption compensatory. Along with, I just did a talk in Salt Lake a few weeks ago and I was looking at the data on weight gain. And predominantly, it was related to carbohydrate consumption, but also alcohol intake. And so, I think it would be helpful for listeners to understand what habitual alcohol use can do detrimentally to our hormones. I’m alluding to estrogen as one in particular, but I think it’s helpful for people to understand that during the pandemic many of us had different ways of dealing with the added pressures and stress of the lack of predictability. Kids being home, who are otherwise normally in school. Maybe there were financial changes or implications related to the pandemic. But I found this very interesting as I dove down this rabbit hole was, alcohol does a lot of different things. I always speak about how it impacts the quality of our sleep. And oftentimes, that’s where I’ll work it in to say, “Okay, let’s examine the relationship with alcohol,” because your goal is to sleep better. But we also know that it dysregulates not just cortisol, not just melatonin, it also impacts our sex hormones, potentially in nonbeneficial ways.


Sara: Yes, ma’am. You just set me up to talk about my least popular topic and that’s fine because our job is to lift people up. And so, that means speaking the truth even when it’s inconvenient. Even when I’m someone who loves a glass of red wine. Yeah, I think all of us have had to look at alcohol consumption during the pandemic and really get rigorously honest about it. What do we know? Well, we know that it not just robs you of restorative sleep, it affects your heart rate variability. I can see that anytime. Yesterday, I had about a half glass of champagne and I could see it in my sleep last night. My heart rate variability, which I track by a few different metrics, I use a ring, I use a smartwatch. What I find is that it drops probably about 15 to 20 points even with a small amount of alcohol. 


Now, I used to get away with more alcohol in my 20s. I think that’s true for so many of us. After 40, alcohol just hits harder, especially for the female brain. We know that heart rate variability. I imagine you’ve talked about this before in your podcast. It’s that lovely measure. It’s one of the biomarkers that I think is so important in my patients that tells us about the balance between the sympathetic nervous system, fight-flight freeze, the on button versus the parasympathetic nervous system, rest and digest what I think of as the healing half of the autonomic nervous system. In rough measure, we want heart rate variability ideally around 70 or higher. That’s what I’m looking forward in my athletes. It can’t be artificially higher in some patients who are on certain medications like antihypertensives, so that’s not what I’m talking about but that HRV effect is so important. 


As you said it raises cortisol the next day. Cortisol, I think of as this essential hormone, with all the sex hormones that includes estrogen, progesterone, cortisol. It includes DHEA, estrogen metabolites. With all of the sex hormones which lead to be rebranded, maybe we’ll talk about that separately. But with all the sex hormones what happens when you drink alcohol is that the very thing you think you’re getting from the alcohol, which for most people is relaxation like I just need to transition, I need to wind down from having my kids around me all day, whatever it is, busy work schedule. The very thing you think you’re getting from alcohol, you get very temporarily, and then it totally backfires. It backfires with your sleep. it backfires the next day. And so, cortisol is one effect, raises cortisol the next day. 


The effect on estrogens, the family of estrogens, I think is what is really important to pay attention to, especially for the women who are listening. Because the short version is that alcohol raises your more dangerous and provocative types of estrogens. These are the ones that are associated with greater DNA damage, they’re associated with a greater risk of breast cancer. One of the saddest studies that I ever read, going back to 2011, [unintelligible [00:19:53] et. al., they found that three servings of alcohol, three per week, three servings was associated with a modest increased risk of breast cancer, because it raises these more dangerous and provocative estrogens. We know that alcohol increases the risk of breast cancer. That’s one of those differential effects where women are more vulnerable than men. There’re many other differential effects, where women just– because of our fat mass, because of various reasons with our enzyme production, we just are more vulnerable to the effects of alcohol, including the effects on the brain, the way it shrinks the brain. Those are some of the effects of alcohol. It also can be associated with reducing growth hormone. So, that’s not a sex hormone, but it’s another hormone that’s important with metabolism, not quite as important as insulin and testosterone, but another important hormone to consider.


Cynthia: Well, I’m glad that we touched on this and I’m always very transparent with my listeners that I was never a big drinker, I had a family member that was an alcoholic, so, that definitely made an indelible impression on me growing up. But the one thing I found was, I was always just a social drinker. I went to a party, I might go out with friends, I might have a glass of wine or a martini. In the pandemic, in the midst of a lot of togetherness with my nuclear family, I said to my husband, I said, “Anytime I drink, all of a sudden, I’m realizing my sleep quality is terrible, my Oura Ring is squawking at me, I’ll get hot flashes.” And I said, “I otherwise don’t ever get hot flashes.” And so, it really speaks to the fact that for each one of us, there’s absolutely no judgment. Just understand the net impact of what alcohol consumption can do to our bodies. 


I love that you touched on some of the gender differences, which is a direction I was hoping our conversation would go in. As it pertains to alcohol or nutrition, let’s talk about the differences between men and women. I know the basis of your newest book is really talking about gender differences specific to the ketogenic diet. Why men sometimes seem to have an easier time with a ketogenic diet, and what physiologically is so different about them, and why women have to do things a little bit differently in order to have the equal amount of success or get the goal that they’re looking for attained while still utilizing a lower carbohydrate diet?


Sara: Yeah. Well, there’s a lot of reasons. The first is the testosterone advantage that we have spoken to before that those people who are born with male organs tend to have about 10 times the testosterone that women have or those who were born with female sex organs. The difference is pretty dramatic. It leads to the effect of generally greater muscle mass. For the most part, men can eat more food than women. A big part of that is just this metabolic difference, the difference in muscle mass. So, that’s one reason. Another reason is that, one of the reasons why women have more body fat is that our evolutionary priority, whether you choose to have kids or not is to make babies to be fertile, to make these sex hormones no matter what. 


Cortisol is the highest priority sex hormone, you’ll make that no matter what but some of these other sex hormones, particularly in women, like, estrogen and progesterone, they’re more optional. But the body is designed as you’ve said in previous podcasts I think with Richard Johnson, we prioritize the stain on the fatter side. There’s this asymmetric approach to the evolutionary pressure for us to get fat. Fat is how we produce a lot of these sex hormones. Sex hormones, the entire tree is made from cholesterol. Cholesterol goes on to make pregnenolone, the mother hormone that then turns left to form DHEA, and testosterone, and estrogen family, or it can go in most schematics down toward progesterone and cortisol. So, that’s a big difference. This pressure that females have toward fertility, and toward more fatness, and then also this testosterone advantage. 


There’re some other factors as well. I was just speaking to them related to alcohol and our response to alcohol. Another thing that we’re noticing, especially as we see more women drinking and we see more marketing that’s being done directly by big alcohol towards women is that women get into trouble faster. They do this thing called telescoping, where they can progress from normal drinkers to alcohol use disorder faster than men. Lots of different factors involved in that difference in metabolism. Another factor that’s important and I feel I can geek out about this with you is that when you look at the data on women and blood sugar, I believe a lot of the original cut offs for what makes normal blood sugar, what mainstream uses is a fasting blood sugar of 70 to 99 milligrams per deciliter, prediabetes, 100 to 125, diabetes is greater than 125 on a couple of settings, those cut offs, I believe were in men. 


A lot of the original data was done in men and assumed to apply to women. That’s true across the board, it’s true with the ketogenic diet, it’s true with pretty much any metabolic research that’s been done. That’s starting to change, but it’s slow. But what we know now is that if you look at women who have fasting blood sugars that are in the 110 to 115 range, they actually have more vascular damage, more endothelial damage than their male counterparts with the same fasting glucose. Prediabetes seems to hit women harder than it does men. So, lots of different reasons. I just mentioned at least four of them. I think this research bias is another one that we’ve got to change.


Cynthia: I agree with you. It’s interesting this talk that I gave a few weeks ago, one of the things I was talking about was women weren’t allowed to be in certain types of research. I think it was from 1973 up until the early 1990s. I was unaware of this and yet, we are using these ranges for lab values and extrapolating that there is gender reciprocity. When in essence, we’re not looking at the fact what are the factors that are making women more susceptible. I would imagine as we are creeping closer to middle age and we’re in perimenopause, the five to 10 years preceding menopause, and we’re losing some degree of estradiol signaling and this estrogen loss is intrinsic estradiol changes that are occurring, this combined with whether there’re so many factors that can impact insulin sensitivity, but one in particular is making that transition into the menopausal years. I start seeing more and more women that will say, “But I’m thin.” This term of TOFI, thin on the outside, fat on the inside, we assume because someone doesn’t look obese or isn’t struggling with being overweight that somehow they’re metabolically flexible. I find more and more that I’m seeing women who have a lot of oxidative stress, a lot of inflammation that’s going on internally, and we can look at those markers. But it’s interesting that you’re suggesting that even at those levels that are considered to be prediabetic, women are impacted more greatly than men.


Sara: Yeah, it’s such a dynamic time of change. That period of transition, I used to think it was five to 10 years. And now, I’m thinking actually depending on how subtle your detection is, it can be even longer. I definitely see changes in my female patients starting around 35 to 40. The average age for menopause somewhere around 51 to 52 and that means half of women are after that age. It can be a very long period of time. There’re a lot of things that can change as you described with the women who have this increased fat mass, but they’re relatively thin. What we know is that these changes that occur under the hood with estrogen, with estrogen resistance, with loss of progesterone, with this decline in testosterone, with the decline in growth hormone, what happens is there’s dramatic immune changes. That’s one of the reasons why I think so many women in perimenopause have these reactions to vaccines and long COVID, et cetera. There’re also pretty significant changes in glucose metabolism. As you alluded to through pre-menopause, we don’t see much change except in pregnancy. 


Pregnancy is one of those differences between men and women. I think of it as a cardio metabolic stress test that many of us fail and we don’t even realize it. When I was pregnant at age 32, I did that horrible glucola, where you drink, orange, fizzy, sugary soda, and then you get your blood drawn an hour later. And my score was 134 milligrams per deciliter. The cut off was 135. And so, my doctor said, “Oh, don’t drink juice.” Okay, that was the best she could do at that point, but I sure wish I had a continuous glucose monitor, and I can see how insulin resistant pregnancy made me. There’re all these changes that occur and another factor that I think is also important in perimenopause is trauma. It’s another sex difference. We know that women experience more trauma than men. We know that from the original studies of adverse childhood experiences that were done at Kaiser in San Diego back in the 90s. Women tend to experience more trauma than men or at least they report it more. We know trauma can really start to manifest more hormonal changes, especially in times of transition like pregnancy, like postpartum, like perimenopause, and menopause. So, there’re all these different factors that we have to keep in mind that lead to this incredibly dynamic period.


Cynthia: I think it’s really important because I’d never put those two together before thinking about these transitional periods in a woman’s life making her more susceptible to under stress, susceptibility to autoimmune issues. And so, the listeners, typically I will share, because I think it’s important. I had something called alopecia areata in between my pregnancies. I saw all the specialists, they checked my thyroid, I saw the dermatologist. And actually, what I was told caused it was, “Oh, you’re tiny, you breastfed your kid, you had another pregnancy really close together. That’s why this happened.” Never putting together in my mind that it was an autoimmune issue. And then several years later developing hypothyroidism, which is probably Hashimoto’s, I just haven’t ever had positive antibodies. 


We just think about the cumulative net impact of stress. It’s like a bucket and you keep adding to the bucket. I think for many of us, myself included, I was taught that trauma was big trauma, a rape, a murder, something big and scary. And yet, what I’ve come to understand and believe is that there are a lot of micro traumas that occur throughout our lifetime that can impact us and whether we are able to work through that trauma except what has gone on, talk about it, I think many of us are encouraged just to bury it. “Oh, that wasn’t really a big deal. You got teased, or maybe you had an abusive parent, or maybe you had a bad relationship, it could be a myriad of things, it could just be maybe you lost your job, it could be something catastrophic.” 


I think it’s very interesting that you’re starting to examine this interrelationship between trauma, and autoimmunity, and stress. Because I think every woman out there needs to understand that interrelationship that none of us are in a position where we’re not experiencing– Just the last two years for many people has been a major stressor. I think we will continue to see what comes out of this in terms of long-term psychological impact. I love that you brought that up, because I think probably for every listener, they will be thinking, “What are the things that have occurred in my lifetime that could be impacting my immune system, my gut integrity,” all the things that we’re talking and alluding to in this conversation?


Sara: Yeah, this is the topic of my next book. I’m really immersed in this literature right now. I think what’s important to take away from this conversation is that many of us have that concept like you described of the war veteran, the person who survived trauma and bombings in 9/11, or went to Afghanistan, or went to Iraq, or Viet–. And certainly, we know that the rate of posttraumatic stress disorder is very high in some of those individuals. What I think of as partial PTSD or known more scientifically sub-threshold PTSD that I see so much in my patients. They don’t recognize it as trauma just as you described. I had a patient this week who said, “No, I didn’t have a traumatic childhood. No, I was normal, grew up in Los Angeles, no big deal.” And then I asked him to fill out an ACE questionnaire, the adverse childhood experiences questionnaire. He had an ACE score of 7, which is really high. It’s associated with greater risk of alcoholism, depression, stroke, autoimmune disease, many different outcomes. And yet, his perception is that he didn’t grew up with a traumatic childhood. It was normal. 


I think it’s important for our listeners to consider doing something like these tests here in California. Reimbursement for insurance is tied to documenting an ACE score on your patients. I think that carrot, I guess that’s a stick. I think that incentive is really important to get us all talking about trauma. I used to also think that, well with trauma I’ll just refer my patients to a therapist, not realizing that the patient I have who’s got longstanding cortisol issues, that bucket that you were talking about that keeps overflowing with cortisol, those patients who are chronically struggling with sex hormone issues, with immune issues with kind of those difficulty regulating themselves. Often trauma is at the root of it. In some ways, it doesn’t matter what the trauma was. What matters is your response to it. What also matters is if you had someone that she could talk to you about it, someone who was really caring and could hold space for you. But we know that the bucket that holds the cortisol, that size of the bucket can really be determined by some of these early childhood experiences. It can also be trauma that occurs later with 9/11, with the Holocaust. But that bucket, if we really think about what makes the size of that bucket, trauma is a big part of it. 


One of the ways I think of it, and I’ve been studying this for a few decades is the PINE system, also known as PNAI, but almost no one can remember that. What this stands for is your psychological system, your immune system, your neurological system, and then your endocrine system, all of which are impacted by trauma. We want to be thinking about, “Okay, how’s my PINE working right now?” A lot of women, when they go through perimenopause, they just find that their PINE is not doing what it once did. It’s becoming more dysregulated. It’s not quite as simple as meditating for five minutes or even 10 minutes. Not quite as simple as taking the latest supplement to address your cortisol issues like phosphatidylserine or an adaptogen. It’s also going back and addressing that trauma.


Cynthia: I think it’s so important because it goes back to the root cause, because we can give adaptogenic herbs, we can encourage people to go to yoga, but ultimately, we’re trying to quiet the autonomic nervous system, the parasympathetic. But if underneath all of that we’re not addressing what is the precipitant, we’re never really going to get the resolution because I have so many women that I interact with and I know you do as well that are really suffering through middle age and it probably very likely is if we went back and looked at those early childhood events, there are probably things that were at the basis. Maybe they were able to weather these things, suppress these memories, not deal with the uncomfortable feelings, but all of a sudden, they’re now being forced to. 


Now, I would really be remiss if we didn’t talk about other types of hormones because I know I got so many questions, people were so excited that we were connecting. Let’s talk a little bit more about growth hormone the reason being I think this is one that most women really don’t understand. I found it really interesting. In your book, you talk a lot about ways we can address growth hormone issues with food and different types of strategies. Let’s talk about what’s changing about growth hormone as we’re getting older. How can we measure it? I know we talk about this in the book, but what are some of the things people can be looking out for them?


Sara: Well, what changes, I’ll start with that first is that women make more growth hormone than men until menopause. That’s when we have this dramatic decline in terms of growth hormone production. A lot of women notice that I think of growth hormone in some ways as a secondary player. I joke sometimes that cortisol is, it can be a bully. It’s the highest priority, it’s involved in blood sugar regulation, blood pressure, immune function, it’s what gets you out of bed in the morning with the cortisol awakening response, so it’s essential for life. But these other hormones are of course, important for a life of meaning. A life where hormones are driving what you’re interested in and you’re excited about what you’re interested in. Growth hormone as suggested by the name, it’s involved in growth and repair. You make it mostly at night. And then there’s this issue where women start to make less of it as they go through the later stages of perimenopause and menopause. Some of the signs of that include signs of aging, so like noticing that your skin is thinner, maybe you’ve got some fine lines, more sagginess, a lot of women notice that in their face, in their neck. You can see longitudinal lines on your fingernails. I don’t have a good example for you here, but I used to a few years ago, so longitudinal lines on your nails. 


Some of the changes I noticed when I was in my late 40s and I was really unhappy about were my inner thighs, even though, I exercise a lot, became more saggy. I noticed more fat, especially fatty cushions above my knees. Those are some of the changes that we can see. And of course, it’s involved in belly fat. There’re a lot of hormones involved with belly fat, insulin, leptin, cortisol, but I would say growth hormone is also in important player. All these different factors are things that you can watch for. I’ve got a list of my book of some of the symptoms, the chicken track and then growth hormone itself is hard to measure in the blood. We tend to use IGF-1 as a proxy for growth hormone. The key to keep in mind is that we don’t just want to crank up the levels of growth hormone. That was the trend especially with the anti-aging movement, I would say, 20, 25, 30 years ago. We don’t do that so much anymore. I never thought that was a good idea. I’ve never prescribed it. But one of the things you will see from some anti-aging folks now is the use of peptides to raise growth hormone. 


My preference always is to start with lifestyle, to start with food, I’ve got a food first philosophy that includes eating sufficient protein, eating sufficient healthy fats. We know that whey protein is really helpful when it comes to raising growth hormone, as long as you don’t have any intolerances. And then fasting. Fasting is one of the most effective, I feel I have to give a shoutout to your book here, because fasting is such an effective way to raise growth hormone. Once again, it raises growth hormone higher in men than women. There was one study looking at a 24-hour fast, which I think is in some ways too stressful for the women that I take care of who’ve got issues with the control system for their sex hormones, the hypothalamic-pituitary-adrenal-gonadal axis but a 24-hour fast is associated with a 1,300% increase in growth hormone in women and about a 2,000% increase in men. So, that’s a little ditty on growth hormone.


Cynthia: I just thought it was one of those hormones it’s not talked about as often. I love that you talked about creatine and vitamin D in the book, because I get a lot of questions about creatine. I think for many people, when they think about the association with metabolism, they think just about insulin, I think just about cortisol, and they’re not really realizing there are these other players that play quite a bit of a role in how successfully we can manage and support our metabolic health.


Sara: Yeah, it’s such an important point because I used to be obsessed with insulin. I feel that’s where I really put my focus when I started to pay attention to metabolism, especially my flagging-waning metabolism after the age of 40. And so, I worked so hard to address insulin. I found that while I made a lot of progress, and I improved my fasting blood sugar, and my postprandial excursions, it still didn’t get me quite where I wanted in terms of energy and in terms of having the body composition that I want going into my 50s, 60s, and 70s. That’s what got me to look at this broader spectrum of other hormones. Another factor that I think is important is, we talked about trauma earlier and I haven’t seen data looking at trauma and growth hormone. But certainly, trauma affects cortisol. Certainly, it affects insulin. The other piece that I think is important more so for women than men is food addiction, disordered eating. In some ways, I feel I really impacted my metabolism when I was in my teenage years. I started to have some habits around eating that were not serving me well. I had a period of time of restriction and I think that set me up for almost the refeeding response that you can get when you start to eat a more normal amount of food. I see in a lot of my patients, the residual of eating disorders. So, this issue of metabolism, I don’t want to just pin it to perimenopause. I think it’s something that we develop a relationship with our metabolism starting very early on. it starts in utero. It probably starts with our grandmothers, with our great grandmothers. 


We know that from the research looking at epigenetics that if you just look at women who go through a significant trauma when they’re pregnant, we know that there’re two sets of genes that are strongly affected by that trauma. One is metabolic genes and the other is immune genes. We’ve got to be looking more inclusively and also realize that this relationship to metabolism, the way you decided how much protein to eat when you were a teenager. Think about that. I was not eating enough protein. This was the days of Dean Ornish. I was eating a ton of pasta with no fat. I had a high-carb, low-fat diet, which does help with blood sugar. But for me, it was not sustainable and it didn’t help me preserve muscle mass. 


Cynthia: I think that’s really interesting because I know that we’re from the same era. And so, I too believe that habits that I developed growing up. My mom was Italian. We ate homecooked meals, and I ate organ meat, and my mom was crunchy, she made bread. She was crunchy before we knew what that was. That concept of being very focused on having a garden, and growing things at home, and really not eating out. I developed a lot of healthy habits, but there was never an emphasis on consuming a lot of animal-based protein predominantly. And so, I remember going off to college and I ate just a lot of carbs, I think most college kids do, it is usually cheese, pasta, bread, etc. It wasn’t until I started getting into my 30s, and became a parent, and had a demanding job working for a cardiology practice and oftentimes is left to deal with some very acutely sick patients that this creep of the understanding that, “Okay, I don’t have the energy that I need. I’m not sleeping well. What could I be doing differently?” And so, I agree with you. The imprinting starts early for us. We just don’t realize it until we fall into the or walk off the abyss into middle age. I agree that it we can’t just pin it on middle age. You can’t just be, “This is just a byproduct of sarcopenia or loss of insulin sensitivity.” We’ve been setting these things up for many years, whether it’s bone metabolism, muscle metabolism. It’s not just perimenopause and menopause. We’re setting the stage our entire life and I’m hoping that we will be able to educate younger generations to be thinking about these things thoughtfully way before they get to the age range that we’re in. 


Now, one thing that I thought was really helpful in your book and I love that you touched on the role of detoxification. I think it’s gotten a bad rap, there’s a lot of misunderstanding and nuances. Detoxification is not just taking a bunch of products. But I love that you talk about the physiology in the body about how we break down hormones properly in our bodies. We have two phases in the liver, we’ve got one in the gut. Let’s talk a little bit about that. Because this is always something I struggle with, when I’m trying to educate women, when we’re trying to put ourselves in a way that we can support our bodies in a very natural way without having go to extremes. I think that’s probably the best way to touch on it.


Sara: Yeah. Well, I work in a mainstream medical system still. I am in a department of Integrative Medicine and Nutritional Sciences at Thomas Jefferson University. We still get the same pushback from mainstream medicine, which is the body detoxifies just fine on its own. There’s no need to augment it. That’s ridiculous, you’re not making any sense here but then if you go to the scientific literature or even just go to take a look at the functional medicine labs on your patients, what you see is that many of us don’t detoxify very well. My practice is full of people who do not detoxify well. Their detox pathways just aren’t open the way that those mainstream medical physicians think they are. 


What I see routinely because I do precision medicine, I do deep phenotyping, I do genomics together with looking at advanced lipid profiles, advanced cardiometabolic biomarkers, I integrate wearables, I do metabolomics looking at hormones, I do nutritional testing looking at micronutrients and organic acid testing. What we know is that many folks just can’t detoxify the endocrine disrupters, the heavy metals, they might be missing GST. That’s one of the things that affects me. Their glutathione pathway just doesn’t work the way that it should. Methylation is another really important part of detoxification. It’s one of those biochemical terms that I think loses a lot of people in the room. It’s really as simple. It’s just adding a carbon and three hydrogens as a group to a chemical, but people’s eyes glaze over when you start to talk about it. The way I think of methylation is that when it comes to detoxifying estrogen you got to methylate to deal with those dangerous and provocative estrogens. You got to methylate them.


Now, glutathione is also involved. But when it comes to methylation, what I do is start with food. Getting those good B donors, those methylating B vitamins, the things like dark green leaves, cruciferous vegetables, beets, there’s lots of different things that help you with methylation and I think that’s such an essential part. In my book, Women, Food, and Hormones, what I do is I start with getting this detoxification in place first before you go to ketogenic diet. Now, keto, that’s adapted for women, but still, what I found when I filled keto myself a couple of times was that if I didn’t have that detoxification in place, I just seem to run into problems with ketone production. I just couldn’t clean up the mess unless I had that detox in place, those detox pathways that were open. Yes, I think detoxification is so essential. Sometimes, there’re supplements that can help you with doing that. But I would say, start first with food. simple things like the methylation that we talked about, as well as fiber. Fiber, I know it’s not so sexy, but man it’s one of the simplest ways that you can get your estrogen back into balance, so that you’re not endlessly recirculating it like bad karma. It’s really important. And very few of us get enough fiber.


Cynthia: Well, it’s interesting. I think this statistic I was looking at traditional hunter-gatherer societies versus people consuming a Standard American Diet, and they were saying, people that consume the standard American diet were maybe getting five to 10 grams of fiber a day. The other little caveat, little dovetail and I’m actually homozygous for a 677-T. I’m completely all over the methylation piece as much as possible is the role of understanding that even if you’re having a bowel movement every day, you may not be properly detoxifying and getting rid of some of these non-beneficial estrogen compounds. I think that’s one of the surprising things. Sometimes, when we’ll run a DUTCH and we’re looking at a GI map, explain to women, I know you’re saying, you’re having a bowel movement every day, but we’re not properly detoxifying, breaking down through these different phases, getting rid of the excess estrogen. It’s not just whether we’re taking synthetic estrogens or we’re using hormone replacement therapy. The fact that we are exposed to so many estrogen mimicking chemicals in our environment, our personal care product, and our food really does have a profound net impact on our endogenous, the hormones that our body is making naturally.


Sara: Yeah, those are such important points. When I wrote my first book, The Hormone Cure, at that time, the data really showed that the average woman in the US was getting about 14 grams of fiber, which is a little more than you describe with a Standard American Diet, but not by much and 14 comes nowhere near the dose that you need to keep some of these hormones in balance. We need somewhere around 35 to 50 grams. If you look at those paleolithic hunter-gatherer populations, they were getting about 50 to 100 grams of fiber. Now, I’m not saying start doing that tomorrow. You’ve got to slowly let your microbiome adjust to consuming more fiber. But yeah, you’re right. There’re so many different factors here. When I think about the hormone system, I’m a bioengineer. I think in terms of, what are the levers, what’s the control, because it’s not quite as simple as just add more fiber and that fixes everything. There’s the hypothalamus and pituitary in the brain, how that talks to a number of different endocrine organs including your adrenals. So, that’s the HPA axis, the gonads, so, testes in men, ovaries in women. It talks to the thyroid and it talks to the gut. The gut is so essential here. 


Hypothalamic-pituitary-adrenal-thyroid-gonadal gut axis, we want to be thinking of all of this and as you described, now one of the issues with having excess estrogen and having this recirculation is having too much of an enzyme called beta-glucuronidase and that BG is produced by at least three species of bacteria in the gut. If you have excess levels of those particular bacteria, that’s what’s making you recirculate with high levels of this BG enzyme. I think it’s not that everyone has to do functional medicine testing to stay on top of their hormones, but we want to be thinking in terms of, “Okay, what hormones are out of whack and then first what are the food and lifestyle base changes that we can make to try to get these hormones back on track?”


Cynthia: It makes a lot of sense. I think for a lot of people that are listening, if it sounds overwhelming, I love that you focus on nutrition-based interventions first, and then digging a little deeper if need be. Now, I want to be respectful of your time, but I would be remiss if I didn’t jump on the one question that I was asked the most often when I mentioned that we were going to connect. What are your thoughts on how to address plateaus? We’re very much a toxic diet culture, we’re very focused on the number on the scale instead of as I always refer to them affectionately as non-scale victories. But for women that are experiencing a plateau, if they’re looking to move the lever in a different direction, what are some of the first things you start thinking about for these women beyond just the hormone piece per se?


Sara: It’s a great question. I agree with you. You gave this caveat. Yes, we’re in a toxic diet culture. And to me when dealing with plateaus, because I’ve dealt with my share of them, I think it’s important to focus on metabolic health. By that I mean, if you’re hitting a plateau, get testing, first of all. Take a look at your metabolic hormones, what’s going on with your fasting insulin. Ideally, I like to look at postprandial insulin. I like to do a two-hour oral glucose challenge test. If you can afford it, do it with a continuous glucose monitor. Because when I hit a plateau, when I was on the ketogenic diet as I mentioned, I kept failing. What I found was that there were certain foods that were triggering my glucose to go up that I didn’t know about, so it allowed me to really personalize my diet and it really helped me break through plateaus. 


Now, we’ve already talked about how plateaus in some ways are normal after age 40. One of the things that happens is that and I think women, especially have noticed this, every decade after 40, you gained five pounds of fat and you lose five pounds of muscle. It could be at age 45, or 47, or 50 that the scale is the same and you feel like it’s stuck. But it may be that you don’t have as much muscle mass to help you with your metabolic health. I think additional testing looking at hormones, so, I talked about insulin, I like to measure free and total testosterone, I like to look at the dance between estrogen and progesterone just see where you are especially if you’re in perimenopause. I like to look at IGF-1, I like to look at leptin, sometimes, adiponectin. Those are the hormones that I like to look at. I like to add on a continuous glucose monitor and then body composition, I think the bathroom scale is not a measure of metabolic health. 


I wish we could do away with them in some ways. I think doing a body composition where you know what your lean body mass is and you are focused, you’re zeroed in on preserving that muscle mass as you get older, which is one of the best predictors of health span that period of time that you feel fantastic. I think that’s essential. And then you’re working on trying to bring your body fat down. So, to me, in a plateau, I would reframe, redirect the client toward focusing on body composition and metabolic health.


Cynthia: No, I think that’s really helpful. I think on so many levels and I hear this almost daily, in fact, I had a discovery call right before we jumped on our podcast recording. The woman very appropriately was noticing all these hormonal changes and it was evident this was perimenopause, a lot of what she was experiencing. And she said, “I keep gaining and losing the same five to seven pounds no matter what I do.” She said, “It’s almost my setpoint has changed.” A lot of what you’re alluding to are the changes that are occurring in our bodies and the reframe of focusing on metabolic flexibility. I actually say all the time that metabolic health is wealth. And that’s how we have to protect it and do the things we can to invest in it to ensure that we remain as healthy as we can throughout our lifetime. 


Because on a lot of levels, I went to a high school reunion a few years ago, and some people were doing really well, and some people weren’t. And they kept saying, “What are you all doing differently?” And they said, “Well, it could be–” I named like five things. And so, I’d never even thought that I need to eat less often, I’d never even thought that maybe sleep was playing a role in this, I never thought that foods that maybe I tolerated in my 20s and 30s are now profoundly inflammatory. I think I’ve mentioned gluten and dairy and that’s very highly bio individual. But just to consider that maybe if to course correct a little bit as you’re chronologically getting older in order to maintain that metabolic flexibility piece.


Sara: Yeah, that’s so essential. I like how you broaden the scope to include all these different factors. How you eat, think, stress, sleep, the way you connect with other people, all of these are important. You may think, “Okay, what does that have to do with a plateau?” It does have to do with a plateau. When I was struggling with a plateau a few years ago, one of the things I tried was to go 100% plant based. I wanted to really see if I could shift my microbiome in the direction of extracting less energy from the food that I was eating and I felt I was hungry all the time. That’s the bio individuality that you’re speaking to. I’ve got other clients and friends who do really well when they’re 100% plant based. It’s not the right fit for me. 


For me, an adapted ketogenic diet, adapted for the female body was what really worked to help me with a plateau. But we’ve got to be thinking about this much broader context of all these different drivers of our metabolic health. I like that point about how metabolic health is wealth, I agree with you. It is the engine behind your mission. Whatever it is you want to do on this planet, you got to have metabolic health to do it well. And so, paying attention to that really understanding the metrics of your own metabolic health. Don’t outsource it to some clinician. Really own it and then ideally work with someone a coach, a nurse practitioner, a physician who knows how to guide you, so that you can improve your metabolic health with aging. 


Another factor, we haven’t talked so much about exercise yet today and yet it’s really essential. I found that the stock gap exercise that I did during my 30s and 40s, which was, go outside, go for a quick run. Get on the Peloton, do a 45-minute spin class with Robin. I love Robin. 


Cynthia: [laughs] 


Sara: Do yoga every weekend with my best friend. Those weren’t quite cutting it. When I started to notice these body comp changes after 45 and that’s where I started to do more weightlifting, so that I do about two thirds weightlifting now with heavy weights and I do less of the cardio, like the aerobic exercise. I do about one third of that. So, that’s another thing to consider. In some ways. I don’t even think of yoga as exercise. I just think of it as a way to [still my mind and to let go.


Cynthia: Yeah, exactly. I’m the same way. It’s interesting that when we talk about metabolic health, and speaking about muscle mass, and reminding people that the more muscle mass we maintain, the more insulin sensitivity we have. And so, lifting weights I always say, even if you start with bodyweight exercise, you need to do some degree of strength training. One other thing that I found really helpful/ironic is that my husband and I used to tease the neighbors that would walk after dinner. And during the pandemic, there are a lot of things we couldn’t do. We started doing a lot of walking and now every night after dinner, we walk for 10 or 15 minutes and I remind people that’s a completely easy way to help mitigate your postprandial meal blood sugar is to go take a walk, because we know those muscles, that’s where we store a lot of glycogen. But that’s a great way to help buffer insulin sensitivity. When I wear a continuous glucose monitor, my blood sugar will drop by 20 points with a 20-minute walk. It’s amazing, amazing and super effective.


Sara: Yeah, that’s such a good hack and it’s not just you dropping your blood sugar by 20 points. There was an experiment done looking at, I think of it as the after-dinner constitutional, where you connect with someone you love, you go for a walk, or maybe you walk your dog, and it’s such a great way to minimize those glucose excursions that a lot of us have after dinner. That’s a great way to improve your metabolic health. It also just fills your lungs hopefully with clean air. There’re so many benefits to it. So, I’m giving you a huge high five on that.


Cynthia: Well, thank you. Well, please let my listeners know how to connect with you. You’ve got a very active Instagram account. You should definitely check that out. You do a lot of videos there. How to grab your newest book? I know you’re working on another one. How to grab all of your books? In fact, I have this sitting on my desk, this is– I have both of your books or all of your books, but this one was sitting next to me, because I was referencing something specific for a client.


Sara: Oh, thank you so much. The website is saragottfriedmd.com. Same on both social. Instagram is @saragottfriedmd. And the books are available anywhere books are sold. So, Amazon, Barnes & Noble, your local Indie, whatever you prefer.


Cynthia: Awesome. Well, it’s been such a pleasure to connect with you and I hope you have a wonderful rest of your day.


Sara: Thanks, Cynthia. So fun to be with you.


Cynthia: If you love this podcast episode, please leave a rating and review, subscribe, and tell the friends.