Protocols
Science-based tools and supplements that push the needle.
Source
We recommend using this distillation as a supplemental resource to the source material.
Full Notes
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
- Realized the importance of addressing root causes for better health outcomes
-
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
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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
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