Dr. Sara Gottfried: How to Optimize Female Hormone Health for Vitality & Longevity

Understanding Family History and Genetics

• Important to understand family history, including grandmother and great-​grandmother’s experiences 
  • Genetics and environment play a role in hormone health
  • Intergenerational trauma affects the endocrine system, especially cortisol signaling
• Stages of a woman’s life cycle: 
  • Puberty
  • Pregnancy
  • Perimenopause
  • Menopause
• Genetic components in pregnancy: 
  • Shape of the pelvis
  • Ability to have a vaginal birth
• Female conditions with strong genetic components: 
  • Endometriosis
  • Fibroids
  • Polycystic ovarian syndrome (PCOS)

When to Start Discussions and Tests

• Discussions should start early, as women of all ages can benefit from understanding their hormone health
• In their 30s, 40s, and 50s, women should consider tests for: 
  • Ovarian reserve
  • Hormone levels
  • Gut microbiome
  • Estrogen levels and metabolism
  • Testosterone, thyroid, and growth hormone levels

Nutrition and Exercise for Female Hormone Health

• Omega‑3 fatty acids play an important role in managing female hormone health 
  • Women have specific needs for essential fatty acids
• Exercise recommendations:
  • Balance between resistance training and cardiovascular training for optimal hormone health

Digestive System and Hormone Health

• Women suffer from digestive issues at more than ten times the frequency of men
• Overcoming digestive issues can help resolve related hormone issues
• Tests to consider: 
  • Blood tests
  • Urine tests
  • Microbiome tests

Navigating Puberty, Adulthood, Perimenopause, and Menopause

• Understanding hormone status and trajectory can help women better manage and navigate these life stages
• Hormone replacement therapy may be a consideration for some women

Dr. Sarah Gottfried’s Books

• Women Food and Hormones
• The Hormone Cure “Style” Notes:

Biomarkers for Women by Decade

Teens

• Hypothalamic pituitary adrenal (HPA) axis not fully mature 
  • More likely to skip periods, especially under stress
• Biomarkers to consider: 
  • Cortisol
  • Estrogen and progesterone levels (less helpful due to variability)

20s and 30s

• HPA axis more established
• Best time for benchmarking hormone levels
• Biomarkers to consider: 
  • Estrogen, progesterone, and testosterone (timed correctly)
  • DHEA (dehydroepiandrosterone) and androgen pathway
  • Estrogen metabolites (some protective, others problematic)
  • Microbiome (stool testing) — beta glucuronidase levels

Oral Contraceptives and IUDs

• Oral contraceptives — potential endocrinopathy for women (opinion)
• Copper IUDs — non-​​hormonal, highly effective, and high satisfaction rate 
  • Least used form of contraception
  • Can last for 10 years, providing autonomy and sovereignty over sexual life
  • Some risks associated, but generally considered a good choice

Estrobalome

• Set of microbes and their DNA in the gut microbiome that modulate estrogen levels 
  • Some women have a faulty estrobalome, leading to increased risk of estrogen-​​mediated conditions (e.g., breast cancer, endometrial cancer)
  • Can be adjusted with microbiome-​​modulating nutrients and nutraceuticals

Blood Testing for Biomarkers

• Timing is important for accurate results

  • For women in their 20s, best to test around day 21–22 of their menstrual cycle (assuming a 28-​​day cycle)
  • For women with irregular cycles or older women, timing may be more difficult
    Nutritional Testing and Hormone Levels

• Preferred testing methods:

  • Dried urine for hormone levels and metabolomics
  • Saliva for cortisol (active cortisol)
  • Blood testing for a snapshot of hormone levels (less comprehensive)
• Nutritional testing:
  • Combination of blood and urine tests
  • Micronutrient testing to identify deficiencies (e.g., magnesium)
  • Helpful for teenagers to identify gaps and motivate healthier eating habits

Encouraging Vegetable Intake

• Smoothies as a solution for those who dislike vegetables 
  • Aim for at least three times a week
  • Blend various vegetables (e.g., broccoli, kale, cauliflower) with preferred flavors (e.g., chocolate or vanilla)
• Supplements as a secondary option to smoothies 
  • Not as effective as consuming whole vegetables

Probiotics and Prebiotics

• Limited evidence from randomized trials to support the use of probiotics 
  • Specific probiotics may be helpful for certain conditions (e.g., athletes with leaky gut)
  • Replacement dose probiotics may be useful after a course of antibiotics
• Prebiotics and selective use of polyphenols have stronger evidence for supporting gut health

Testing for Nutritional Deficiencies and Microbiome Health

• Best way to analyze nutritional deficiencies: 
  • Combination of blood and urine tests
  • Micronutrient testing to identify deficiencies (e.g., magnesium)

• Best way to test the microbiome:

  • Stool sample
  • Timing for establishing a baseline may vary, but generally before making significant dietary changes (e.g., increasing vegetable intake)
    Gut Microbiome and Nutrition

• Eating more vegetables can be beneficial for gut microbiome

• Analyzing gut microbiome through tests is not yet clear-cut 
  • Dysbiosis is bad, diversity is good, but specific ratios are unknown

Nutritional Testing

• Antioxidants: Vitamin A, Vitamin C, alpha lipoic acid, plant-​​based antioxidants
• B vitamins: absorption can be affected by genetic polymorphisms
• Glutathione: important for detoxification
• Minerals: Magnesium deficiency is common (70–80% of Americans)

Magnesium

• Measure red blood cell magnesium to determine deficiency
• Supplementation depends on individual needs 
  • Constipation: use magnesium citrate
  • Sleep: use magnesium threonate

Testing Labs

• Genova NutrEval: blood and urine test, insurance may cover
• Metabolomics: finger prick test, more convenient
• SpectraCell: used by some practitioners, but not as popular

Constipation in Women

• 80% of women experience constipation
• Contributing factors: diet, stress, hormonal imbalances, thyroid dysfunction
• Women have a longer gut and are more likely to have a torturous colon
• Colonoscopy recommended at age 50, but may change based on new data

Addressing Constipation

• Constipation can signal larger health problems
• Relieving constipation may help address other issues

• Interventions: increase magnesium intake, consume more vegetables, manage stress, and address hormonal imbalances
  Cold Exposure and Stress Response

• Some people have a gene that makes them stress out with cold exposure

  • For them, even 10 seconds of cold exposure can have an adaptive response
• Cold exposure can be used as a stressor to improve stress response

Constipation as an Indicator of Dysfunction

• Women experience more trauma than men 
  • 60% of women experience significant trauma, compared to 50% of men
• Constipation could be a signal of dysfunction in the autonomic nervous system 
  • Autonomic arousal stress can be related to the need for bowel movement
• Definition of constipation varies 
  • Western definition: bowel movement less frequently than once every three days
  • Personal definition: not having a bowel movement every single morning with a feeling of complete evacuation

Bowel Movements and Autonomic Arousal

• Autonomic arousal increases in the early part of the day, ideally after a good night’s sleep 
  • Bowel movements become more likely unless arousal becomes too great, leading to feeling “locked up”
• Early day and second half of the day are ideal times for bowel movements

Tools to Relieve Constipation

• Eating more fiber
• Reducing perceived stress 
  • Real-​​time stress reduction tools like physiological sighing
  • Long-​​term stress reduction techniques like Transcendental Meditation, yoga, and holotropic breathwork

Breathing Techniques for Stress Reduction

• Box breathing: inhale, hold, exhale, hold for equal durations 
  • Duration set by individual’s carbon dioxide tolerance
• Cyclic sighing: double inhale through the nose, followed by exhale to empty lungs 
  • Second inhale ensures all collapsed avioli in lungs snap open
  • Exhale offloads carbon dioxide

• Cyclic hyperventilation: active inhales and exhales, with exhale hold for 15–30 seconds

  • Similar to Tummo and Wim Hof breathing techniques
  • Performed for five minutes
    Cyclic Sighing Study

• Study found that cyclic sighing led to significant improvements in mood, lowered resting heart rate, and improved sleep

• Published in Cell journal
• Participants were not told to alter any other behaviors, such as alcohol consumption
• Study included Stanford students and general population

Alcohol and Health

• Alcohol intake increased during the pandemic
• Ideal alcohol consumption: no alcohol or maximum of two drinks per week
• Alcohol disrupts nighttime sleep patterns, particularly the first phase of sleep related to growth hormone release

Stress and Patriarchy

• Patriarchy, defined as power over, can contribute to systemic stress in the body and environment
• This can also relate to white privilege and racism
• Systems like universities are often set up in a way that benefits strong, powerful men, creating a different experience for women and BIPOC individuals

Health Monitoring for Women

• Women in their late teens and early 20s should be aware of their testosterone, estrogen, thyroid, and cortisol levels
• Monitoring bowel movements and microbiome health is also important
• These health factors should be considered throughout a woman’s life, with different opportunities for intervention depending on age
• Knowing one’s hormone levels can help inform lifestyle choices and self-care

Testosterone Levels in Women

• Testosterone levels can decline starting in the late 20s, usually by about 1% per year
• A healthy range for women after age 25 is the top half of the normal range

• In women with PCOS, testosterone levels can be much higher (100–200), often accompanied by peripheral manifestations such as excess hair, skin plaques, and irregular periods
  PCOS (Polycystic Ovary Syndrome) Discussion

• PCOS is a poorly understood condition that often goes unnoticed until a woman wants to get pregnant or has other issues

• It is a syndrome with unclear diagnostic criteria 
  • Three main criteria: cysts on the ovaries, clinical manifestations of hyperandrogenism (e.g., hirsutism, acne), and irregular periods
  • Multiple systems for diagnosing PCOS exist, leading to confusion
• Hirsutism: increased hair growth in unwanted areas, often in a male pattern
• PCOS is not just a problem for reproductive age but also a massive risk factor for cardiometabolic disease as women get older 
  • Elevated testosterone and high androgens are significant cardiometabolic drivers for women with PCOS
• Conventional medicine often only addresses PCOS in the context of pregnancy, which does a disservice to women 
  • There is a gender gap in research funding and awareness of sex and gender differences in clinical trials
• Hypothesis: Could PCOS be a response to psychosocial stress and conditions that force women to adapt in certain ways to survive and thrive? 
  • This could be an interesting study to run, looking at the gene-​​environment interface and the role of insulin and glucose in PCOS
  • Hyperinsulinemia (high insulin in the blood) drives cells in the ovaries to overproduce testosterone in some PCOS phenotypes
  • These women are insulin insensitive, leading to more insulin being produced and more androgens being created

Microbiome Testing

• Microbiome testing is a popular and emerging area of research in medicine
• Understanding the microbiome can provide insights into an individual’s health and potential treatments for various conditions

Insulin Sensitivity and Resistance

• Insulin sensitivity is a desirable state, while insulin resistance is associated with various health issues
• The terms “insulin insensitive” and “insulin sensitive” can be confusing for patients, but they refer to the same concept

• Regular blood tests can help monitor insulin levels and overall health, especially when experimenting with supplements and behavioral regimens
  Importance of Blood Work and Continuous Glucose Monitors (CGMs)

• Get basic blood work done for a reference point

  • Useful to know insulin levels at different life stages
• Huge fan of CGMs 
  • Effective at changing behavior
  • Provides real-​​time data on blood glucose levels
  • Helps understand how various behaviors impact blood glucose
  • Democratizes data, empowering patients to take control of their health

Factors Affecting Health and Vitality

• Sleep
  • Essential for overall health and well-being
• Alcohol
  • Limit consumption for better health outcomes
• High perceived stress 
  • Manage stress for better health and longevity
• Eating the wrong foods 
  • Choose nutritious foods for optimal health
• Toxic relationships and isolation 
  • Foster healthy relationships and social connections
• Not moving enough or exercising in a way that fits one’s body 
  • Find the right balance of cardio and resistance training

Exercise Recommendations for Cardiometabolic Health

• About 1/​​3 cardio, 2/​​3 resistance training
• Minimal effective dose: 150 minutes per week
• Adjust exercise routine based on individual needs and body phenotype

The Impact of Chronic Cardio and Cortisol

• Chronic cardio can lead to high cortisol levels 
  • Marathon runners and those who do excessive cardio without resistance training are at risk
  • High cortisol levels can be buffered with vitamin C

• Personal example: High cortisol levels, insulin, and glucose; low progesterone; mildly abnormal thyroid

  • Realized the importance of addressing root causes for better health outcomes
    Adapting Exercise and Lowering Cortisol

• High cortisol levels can be detrimental to health

• Switching to adaptive exercises like Pilates and yoga can help lower cortisol levels

Supplements for Lowering Cortisol

• Ashwagandha: potent cortisol reducer, but data is mostly based on animal studies and Ayurvedic medicine
• Rhodiola Rosacea: shown in multiple randomized trials to lower cortisol
• Phosphatidylserine (PS): 400–800mg dosage, 400mg more effective than 800mg
• Fish oil: modestly reduces cortisol

Timing of Supplements

• Depends on when cortisol is high
• Typically, cortisol peaks 30–60 minutes after waking up and declines throughout the day
• If cortisol is high in the morning, take PS in the morning
• If cortisol is high at night (flat cortisol pattern), take PS at night

Flat Cortisol Pattern

• Associated with anxiety, depression, decreased survival from breast cancer, PTSD, autoimmunity, and fibromyalgia
• Late-​​shifted cortisol has the worst immune downstream issues

Congenital Adrenal Hyperplasia

• One in twelve people may have a mutation in adrenal-​​related genes
• Can lead to either too much or not enough cortisol production
• Hyper-​​producing cortisol can lead to higher rates of depression, suicide, and metabolic dysfunction
• Ability to push through stress and not crash can be both adaptive and maladaptive in certain professions and situations

Toxic Relationships and High Cortisol

• Living with someone who hyper-​​produces cortisol can be challenging

• Biological resilience can lead to staying in bad circumstances longer, which can be a double-​​edged sword
  Omega-​​3s and Supplements

• Omega-​​3s and fish oil

  • Essential fatty acids important for health
  • Controversial topic with varying opinions on benefits
• Personalized approach to omega‑3 supplementation 
  • Measure individual levels with nutritional testing (e.g., Omega Quant, Cleveland Heart Lab)
  • Some people need more than others (1 gram to 6 grams)
• Food-​​first philosophy 
  • Prefer getting omega-​​3s from fish (e.g., salmon, smash fish)
  • Supplement on days without fish intake
• Other supplements
  • Magnesium — many people are deficient
  • Vitamin D — 1000 to 2000 international units per day (dose to serum level between 50 and 90)
  • Phosphatidylserine — not necessary for those with normal cortisol levels

Oral Contraceptives and Health

• Benefits of oral contraceptives 
  • Provides women with reproductive choice
  • Reduces risk of ovarian cancer by 50% after 5 years of use
• Risks and concerns 
  • Vague and nonspecific symptoms of ovarian cancer (e.g., bloating, bulk symptoms)
  • Regular gynecologic exams and monitoring for high-​​risk individuals
• Hormone-​​based contraception for non-​​sexually active women 
  • Mainstream medicine often prescribes oral contraceptives for various reasons (e.g., acne, painful periods)
  • Consequences and pharmaceutical influence should be considered
  • Informed consent is important in decision-making

Alternative Contraceptive Methods

• NuvaRing

  • Hormonal contraceptive device placed in the vagina
  • Releases a continuous low dose of hormones to prevent pregnancy
    Hormone-​​Based Contraceptives: The Ring

• The ring is a hormone-​​based contraceptive that releases estrogen locally

• Less data available on the ring compared to oral contraceptives
• Contains ethanol estradiol and progestin (synthetic form of progesterone)
• Delivered transdermally through the vagina, resulting in lower doses than oral contraceptives
• Risks associated with the ring are likely similar to oral contraceptives, but possibly on a lower spectrum

Oral Contraceptives: Risks and Concerns

• Deplete certain micronutrients, such as magnesium and vitamin B
• May affect the microbiome and increase the risk of inflammatory bowel disease
• Increase inflammatory tone, affecting cortisol production and thyroid function
• Raise sex hormone binding globulin, which can lead to a decline in free testosterone 
  • Can result in vaginal dryness, decreased sex drive, and reduced confidence and agency
  • Can shrink the clitoris by up to 20% and cause regression of nerves that innervate the clitoris
  • Reversibility of these effects is uncertain

Assessing Follicle Number and AMH Levels

• Most women don’t assess their follicle number or AMH levels until they’re trying to conceive or experiencing early menopause
• These tests should be offered more broadly to help women understand their reproductive health
• There’s a double standard in conventional medicine regarding hormone testing for women who are and aren’t trying to get pregnant

Menopause and Hormone Replacement Therapy

• Hormone replacement therapy can be beneficial for vitality and health outcomes if started early enough
• Hormones being replaced typically include estrogen and progesterone
• Knowing your hormonal phenotype in your 30s can help inform future hormone replacement therapy decisions

• The Women’s Health Initiative in 2002 led to a significant decrease in women taking hormone therapy
  Hormone Therapy for Women

• Millions of women suffer from insomnia, mood issues, and low sex drive due to lack of hormone therapy

  • Hormone therapy is safe when given judiciously within 5–10 years of menopause (around ages 51–52)
• Women’s Health Initiative (WHI) study had flaws 
  • Wrong study, wrong patients, wrong medications, and wrong outcomes
  • Study used synthetic hormones, which may have greater risk of breast cancer
  • Reevaluations of data show no increased risk of breast cancer
  • Women aged 50–60 within ten years of menopause had the greatest benefits from hormone therapy

Perimenopause and Brain Changes

• Perimenopause: period before final menstrual cycle, can last up to 10 years 
  • Symptoms include closer menstrual cycles, poor sleep, anxiety, and difficulty with memory
• Massive changes in female brain during perimenopause 
  • 20% decline in cerebral metabolism from pre-​​menopause to perimenopause to post-menopause
  • Women with most symptoms have the most significant cerebral hypometabolism (low brain energy)
  • This may be a risk factor for Alzheimer’s disease

Hormone Therapy and Alzheimer’s Disease

• Hormone therapy in 40s and 50s may help reduce the risk of Alzheimer’s disease 
  • Conventional approach is to only offer hormone therapy for severe hot flashes and night sweats
  • Hot flashes and night sweats are biomarkers of cardiometabolic disease, increased bone loss, and brain changes

Ketogenic Diet and Metabolic Flexibility

• Ketogenic diet and intermittent fasting can increase cells’ sensitivity to insulin 
  • Beneficial for brain health and reducing risk of dementia, especially in women
  • Pulsing between ketogenic diet and typical eating patterns may be more beneficial than staying on a ketogenic diet long-term

Stool Testing Recommendations

• Genova one-​​day stool test: good copay system with insurance, useful for gut health assessment 
  • Three-​​day test recommended for those with potential parasite concerns

• Onegevity Gut Bio test: powered by AI, provides dense data on gut health

  • Easier to use (wipe instead of digging through stool)
  • Recommendations may be biased towards Thorn supplements
    Female Hormone Health, Vitality, and Longevity with Dr. Sarah Gottfried

• Dr. Gottfried has shared immense knowledge on female reproductive health, contraception, diet, microbiome, and the psychosocial impact on health

• Brain communicates with the body, linking psychology and biology
• More topics to explore in future discussions: PCOS, menopause, contraception, and the use of specific medicines, including plant medicines, to influence overall health

Important Health Tests

• Coronary Artery Calcium (CAC) Score
• Recommended for both men and women by age 45
• CT scan of the chest, can be self-ordered
• Provides insight into cardiometabolic health and potential risks
• Adverse Childhood Experiences (ACE) Score
• Essential baseline for understanding the impact of childhood trauma on health
• Helps identify potential links between trauma and health issues in adulthood

Dr. Sarah Gottfried’s Books and Social Media

• Women Food and Hormones
• The Hormone Cure