Thyroid Problems in Women Skyrocket During Perimenopause + What to Do About It | Dr. Christine Maren

At age 40, we're seeing a decline in microbial diversity for women and that correlates with parimenopause. And we see that menopausal women, their gut microbiome resembles the gut microbiome of a male. So when a female has the gut microbiome of a male, there's more inflammation and more immune reactivity that goes on. Gut microbiome is shaped by your hormones. And at the same time, your hormones are really shaped by your gut microbiome and all of that downstream effect influences immune system and the autoimmune disease, which is going to impact thyroid function. So talk to us about sex hormones, thyroid, what do you wish parimenopause patients knew? Dr. Christine Maren is a board certified physician and functional medicine expert who specializes in uncovering the root causes of hormone, thyroid, gut and autoimmune issues. With her signature three-pillar method and advanced training in women's health, she empowers women through every stage of life, from fertility and postpartum to parimenopause and beyond. I do not think that birth control pills are a good treatment for parimenopause period. Yes, they provide contraception, but there can be some serious risks, especially as women are aging, which includes things like, why do you think it is that thyroid health in parimenopause is getting like no airtime on social media, yeah, major media, literally nowhere? I think it's because most of the people talking about menopause are talking about. is. any ton of resources to support you on your journey. Let's dive in. We're going to be diving into gut health, specifically as it relates to parimenopause and menopause, but we've got to start this conversation with thyroid because for whatever reason, thyroid is like this stepchild of hormones currently, like nobody wants to see it, nobody wants to talk about it, and everybody who has become very prominent in talking about hormones on the internet just forget that thyroid exists altogether, and yet it's a super big concern for women over 35. Can you talk to us about what women should know over 35 about their thyroid health? Yeah, I mean, as you said, don't forget about thyroid, menopause medicine doesn't always address that. So, yeah, women over 35 women in parimenopause definitely experience heightened thyroid symptoms. I always call this the unmasking effect, like any underlying condition gets worse in parimenopause, like rip off the band-aid. So with thyroid, you know, there's a lot of symptoms that can correlate with parimenopause. It's not always just parimenopause. So it might be fatigue, brain fog, weight gain. I mean, there's a lot of overlap. There can also be changes in our period, and you know, the kind of classic ones is like hair loss and constipation, but I think it also contributes to dysregulation in the gut, which might also lead to SIBO. There's a big correlation there. And of course, there's this autoimmune component. And so, if we're looking at Hashimoto's, which is the number one cause of hypothyroidism among women in the United States, that's a big one to consider, especially since we see an increase in autoimmune disease through parimenopause. So yeah, there's this huge connection for women over 35. So test it. I mean, I think the big thing is getting lab done, getting comprehensive labs and looking not just at TSH, but a more comprehensive thyroid panel. I want to talk about a more comprehensive thyroid panel. First, for everybody listening SIBO, small and testibacterial overgrowth, they're good bacteria. We love them. They just get in the wrong place and they cause trouble. But as you were saying all this, you said, you know, not everything when you're in parimenopause is just parimenopause. You're right. I mean, I was traveling through Columbia and I didn't realize this was what was going to happen, but we went and stayed at a mutual friend's house. And before we knew it, there was a line of people to come see me. And I was like, what is going on? And they were like the American doctors here. And then like, hold up. Like, I know, licensed here. But one of the things that came up, his wife was having heart palpitations. She was really, really tired. She was losing her hair. And she was saying to me, like, my skin's getting so dry. And she's like, I saw the doctor and he said to me, you're just getting old. This is how it is. You're in the change. And I was like, has he checked your thyroid? And so I gave her a list of tests. I'm like, you know, minimum, get a TSH, go check it. She comes back. She's like, I'm hypothyroid. Like, I wouldn't have known that if you weren't here. And I'm like, that is such lazy medicine that we see happens so often to women is you're just getting old. Yeah. So tell us how would someone differentiate between parimenopause and hypothyroidism? So everybody listening, there's hypothyroidism, too much thyroid hormone. We'll talk about that in a minute. But hypothyroidism too little. And that's the most common. So that's why I want to start there. Yeah. I mean, thyroid is not that hard to test for. Parimenopause is kind of hard to test for. Yeah. I mean, that's largely symptomatic. But I think you have to rule out other conditions first while you're looking at parimenopause. So get a TSH. I mean, in my clinic, I order a TSH of free T4, a free T3. I like to look at reverse T3 and thyroid antibodies like thyroid glabulin, thyroid proxidase. And if somebody has a TSH, that's high. That's indicative of hypothyroidism. There's other causes of hypothyroidism that are less common. Some women have a normal TSH with a low free T4. So I think it's really imperative to look at both. And that's not always done in conventional medicine, like in my family medicine training. We were taught to look at TSH. And if that's abnormal, then you look at a free T4. I would at the bare minimum look at both TSH and free T4. Free T3 can give you a lot more information about how your active thyroid hormone is interacting with the cell. But I mean, labs, I mean, they're not expensive. I think if you're, if you're being dismissed and told you're getting older and it's just something to suffer with, like put your foot down and you have to advocate for yourself and get labs drawn elsewhere. Either with a different clinician or even on your own, but I really believe women have to advocate and get labs drawn. Yeah. It's so interesting to me in the United States that there's so much gaping with patients data that, you know, now we have a lot more access, but it used to be like, you could only get your labs and you went to a doctor and then you can only get your results when you see the doctor again. Other countries are like, that's the patient's data, they own that, and it's their responsibility to take it to their provider. Like we give it to them. And I just think that is part of the problem of why people don't get the care they actually need when there is a problem. I agree with you. It's a hard question for me to answer. I think about this. Why don't doctors order these tests? I mean, what's the problem? But they're, they're taught not to. And part of it is financial insurance companies save money when we order less tests, although a TSH is like four bucks. It's so cheap and it's so easily available. In my mind, I think, okay, risk and benefit. What's the risk of ordering this lab? Purely financial. And it's a very little, like four bucks, right? Why not? Why aren't we ordering this? But the big organizations and, you know, ACOG and whatever, ABFM, I mean, they don't always recommend that we order a TSH. I mean, it's sort of like in fertility medicine when we see women with recurrent pregnancy loss. Like maybe we'll order a thyroid hormone then, but when women are trying to conceive, we don't do it either. I think it's a really big miservice to women. Yeah. And, you know, to that point, I think that, you know, unless you've been in that loop of infertility, you don't know that they'll oftentimes let you have three babies that you lose. And I say babies because when you're trying to get pregnant and you do become pregnant and you have that loss, that is your baby. And you feel that. And medicine is so callous about it. They're like, yeah, once three, then, then we'll work things up. And I just think, you know, every time I meet with a reproductive endocrinologist on this podcast, which I'll link some of those episodes, they're like, that is a huge mistake that we're making and it's costing women time. But also nobody seems to care about women's mental health. Like they just don't care if that's the algorithm they're following. Yeah. I mean, I agree with all that. Let's go through thyroid. So you said TSH. So for rebalancing, that's a brain hormone. That's what the brain says to the thyroid. We know that sometimes doctors are going by reference ranges that might be like 10, 15, lay, and they're like, yeah, well, you're 14. So you're fine. What's an ideal TSH that you're looking for? I like TSH between one and two. So once TSH climbs above 2.5, I just, I start to watch it a little bit more closely. I don't always treat if TSH is above 2.5. In conventional medicine, your TSH is going to be like usually above 10 before you get treatment. It's sort of like a watch and wait for you to suffer. Though again, risk benefit, there are risks to taking too much thyroid medication for sure. But that's too much if it's well managed and it's not dose too high and you get your TSH between one and two. That's like the sweet spot for me. Yeah. And you mentioned that sometimes the TSH is normal, but the free T4 will be low. Explain to people what that means. So secondary hypothyroidism can happen where your TSH that brain-based hormone isn't responding to low thyroid hormones. So if you have low thyroid hormone and you're not producing enough, there should be this feedback loop that tells your brain like, hey, kick on and your TSH will increase as a way of like knocking on thyroid store to say, hey, give me more hormone. And then you make more T4 and more T3. But that that doesn't always happen. And so-- Some people will have a low free T4 with a normal TSH, and then they'll have a low free T3, of course, too. If you don't have enough T4, you're not gonna have enough T3. - Can you explain that? 'Cause I don't think I'm gonna be able to say that. - So I don't think everyone does. - T4 converts to T3, and T3 is really the active hormone. That's the most important. Like that is what interacts with your receptors. And so that's your active hormone, but you've gotta have enough of the raw material, which is T4, you strip off an iodine, and you get T3. And so that conversion, sometimes we talk about women who under convert between T4 and T3, or have like low free T3 syndrome, that low T3 can contribute to thyroid symptoms. - Mm-hmm. - But it's not always a thyroid problem. This is where it gets a little bit in the weeds. So some women will have a normal T4 and a low free T3, and that low free T3 tells me, hey, you're not converting that well between T4 and T3, but that's not really the problem with the thyroid in that case. It's a problem with conversion, which is often a problem with inflammation, high stress, certain nutrient deficiencies, not enough food, like a caloric deficiency. That's one of the huge ones where women are under converting. And it just goes back to, in everything I think, well, how's this keeping us alive? Because that's the real, I always say your body loves you. It's trying to protect you. And that is our body's mechanism of trying to keep us safe and protected, but it's really like, it's slowing down our metabolism. So we have to figure out what's going on there. And often it's also rooted in gut. - Mm-hmm, yes, which is what we get. Talk about gut. - Yeah, you can't talk about the thyroid and not talk about gut. It's like a must. - Yeah. - So get there, you promise everyone, but I want to get into the B3 and the reverse T3, not a lot of doctors order reverse T3. And some things, if I'm doing a CRP and I won't always include the reverse T3, depending on how much the patient's budgeting for labs. Because unfortunately in the United States, this is a big part of the conversation is like how much do you think it costs? And if people are like, well, why is that? If your CRP is up, I already know your reverse T3 is up. But let's talk about the, 'cause I do think there's value in the reverse T3. I hate when I have to pick and choose because insurance is just a pain, you know? - Yeah, totally. Yeah, reverse T3 is a great marker. I really like it actually when I'm dosing GLP ones for weight loss because it's a good indicator for me if women are getting enough food. And a lot of times the trend I see, 'cause their appetite will be suppressed on a GLP one, they'll stop eating and their reverse T3 will go up. And that's the sign that your body's like putting on the brakes. So reverse T3 is the brakes, free T3 is the gas. So you slow your metabolism down when reverse T3 goes up. But again, it's your body trying to protect you. It's slowing your metabolism down saying, hey, I don't have enough food, right? So that's that sweet spot. Also with inflammation, it can go up. And so yeah, reverse T3, I mean, it's there for a reason. It protects us in certain instances in our modern day world. Doesn't always let us like lose weight and feel great and have great energy if we're not giving our body what we need. But I do love checking a reverse T3. I tell my patients, it's not a deal breaker if I'm assessing thyroid function. But it's a really great piece of data for me. I mean, cash pay price in the United States is about like $38, depending on what lab you go through, of course, but, you know, so it's not like, it's not like a CT scan. I mean, it's not hundreds of dollars, but yeah, it can be a good indicator. Yeah, I like to call it reverse T3, the hibernation hormone. Yeah, I'm like, when it docs on your receptor, you are a barren winter. You are gaining weight. You are super irritable and cranky. You want to sleep all the time and you're hiding away from everyone because this reverse T3 is going up. There's usually issues with the HP axis as well. And so our resilience distress begins to disappear. So you're literally just like, I need to be in a cave, lot of me live in a cave. Exactly. That's, I tell my patients, this is like, you're in hibernation mode. I call it hibernation mode when reverse T3 goes really high. And then I explain to them, I mean, think of it. If you're in a cave and you can't find food, what do you want to do? You want to slow down your metabolism, conserve all your resources. That's why you drive up reverse T3. It's there to protect you. And it's also a signal to us that like, hey, you're not getting enough food or you're under too much stress or whatever it might be. And it's also something really important for people to understand is that this is a big flair of the system is under too much pressure because where most conventional medicine is actually familiar with reverse T3 is the studies on people who have had traumatic events, gone through car accidents and we know and elevated reverse T3 is associated with four outcomes, which is usually you're expired. And I'm trying to walk the line with social media and not getting censored here, but it's not a good sign. And so I think it's a really important thing too that somebody who goes through a divorce, they have the loss of a loved one, loss of a pet. They've had something really traumatic is having that test to be like, where are we at? How is your system responding? Because unfortunately for women, especially in the United States, but it might be true in other countries, I just don't treat other people in other countries. You usually have to have data in front of you to give you permission to slow down and until something is like black and white objective data showing you you have to slow down, usually women are like, I need to suck it up, I need to push through it, I need, you know, because there's just a lot weighing on our shoulders. Totally. When we talk about gut health, probiotics are absolutely part of the conversation, but they're not the whole story because your gut bacteria that keep estrogen optimized need to be fed. And that's where compounds like polyphenols come in. They help support microbial diversity, gut lining health, and overall digestion. That's one of the reasons I've been incorporating peak T's Puer T duo. These high quality T's ensure you're getting both polyphenols and naturally occurring beneficial compounds that help support the gut environment. The green Puer is rich in catechins, which help nourish beneficial bacteria and support cellular health. And the block Puer is fermented, so it's especially supportive for digestion, which is why I highly recommend it after meals, especially if you want to feel less bloated and more comfortable. This is the kind of tasty daily ritual that helps support the entire gut ecosystem and support balanced digestion. If you want to give it a try, head to doctorbrighton.com/peaklife. That's dr-bi-g-h-t-e-n.com/peak-g-t-e-n. P-i-q-u-e-l-i-f-e. You'll get 20% off your first purchase. That's dr-bi-g-t-e-n.com/peaklife. Yeah, I mean, I talk about this all the time. Women push through. We are so tough. We are so resilient. And we can't do this forever. We can't overcompensate and overperform forever. Eventually, it catches up with us. And yeah, to see it on data is helpful. I feel like parimenopause is sort of that biological timepiece that says, "Okay, time to take care of you now." Yeah. Why do you think it is that thyroid health in parimenopause is getting like no airtime in social media, major media, literally nowhere? Yeah. Well, it's a good question. I think it's because most of the people talking about menopause are talking about, you know, menopause medicine. They're talking about estrogen progesterone, maybe testosterone. But thyroid is sort of left out and lost in that conversation. You know, it's like an endocrinologist. Usually treats thyroid. Most endocrinologists don't really treat menopause. Some OBGYNs treat menopause, but not really any OBGYNs treat thyroid health. Primary care doctors often don't know much about menopause. You know, it's just lost in the conversation. So, I mean, that's where a functional medicine lens and menopause medicine lens, like all combined, is really useful because as you know, like thyroid, estrogen, progesterone test, like they all go together. The other thing that's really interesting we got to talk about is like how those other sex hormones influence thyroid because they're all connected. Yeah, no, I was actually going to bring that up because I feel like you absolutely cannot do menopause care and not also be managing thyroid health. And if you don't know how to do thyroid health, like this is not looking good for your patient. And maybe you can have another team member and you're collaborating together, but the reality is, here's the thing. You know, in the uterus, we're just going to give you estrogen. Okay, never mind. Let's forget the fact that without progesterone, you actually don't utilize your thyroid as well. So, but we can just forget about that, right? Because you don't have a uterus. We're just thinking about your breasts and your downstairs and anything that covers a bikini and your brain. Don't worry, you're pretty head about that. Like, you know, you were always a little anxious anyways, right? Like it's a big disconnect going on. Yeah, totally. It's a huge disconnect. Yeah. So talk to us about sex hormones, thyroid. What do you wish Perry-Mennipause patients knew? Yeah. Well, get your labs tested and it could also be thyroid. Like, yes, it's perimenopause. And there are other things that happen here. So in terms of thyroid, what's really important is for women who are on thyroid medication, you always want to have your labs rechecked after starting or adjusting your dose of thyroid medicine, which seems like an obvious, but believe it or not, it's like not done all the time. I always check anytime, you know, my patients know this. You're going to get your labs run in six to eight weeks after we adjust your thyroid medication. I do the same thing after starting HRT. So if we're going to start HRT, whether it's estrogen, for gestural and testosterone, we're gonna reach out your thyroid as well, because testosterone might decrease your need for thyroid medication, whereas estrogen might slightly increase your need. Most of the time I don't see that happening, for sure with birth control pills, that's a whole other topic about sex hormone binding globulin and maybe we'll go down that rabbit hole, but with transdermal estradiol, it maybe will affect thyroid hormone, it's a possibility, and maybe will mean that you might need slightly more medication, however, it improves the way that your medication works or improves the way that your thyroid hormone receptor sensitivity works. - Yeah. - When you're talking about birth control, that also falls into any form of oral estrogen. - Yeah, raises sex hormone binding globulin, that's gonna grab your estrogen and your testosterone. This is why anyone listening, if you're like, I didn't have a libido in my 20s and 30s, because you were on birth control, you were gobbling on these two primary their called sex hormones, they do a lot of things in your body, but estrogen, definitely for women and testosterone are so important in sexual health. So you were talking about the difference between oral estrogen and top of the estrogen, and I want to really hone in on this birth control, conversation for a minute, because so often we see doctors say, just take the birth control pill for your parimenopause. Why is not so problematic, especially through the lens, the changing dynamic of thyroid health? - Yeah, I have a lot to say about this, and most of it's not good. So yes, they provide contraception, but we have better, safer ways to provide women with contraception. So back to the risk-benefit discussion, let's just talk about the risks, first of all, with birth control pills, there can be some serious risks, especially as women are aging, which includes things like blood clots. I mean, they're big risks, and while they're not super common, they're common enough that every time I give a talk, somebody comes up to me and says, "Oh, I was that woman who got a clot in my brain, or whatever it might be." Like, it's real. Also, it decreases libido. Like it increases sex hormone binding glibulin, which binds up hormone. So it's gonna bind up free thyroid hormone. It's gonna bind up free testosterone. So lower libido, lower thyroid function, it's gonna deplete certain nutrients. It's just why? Why are we using that to treat parimenopause? We have better options and they're safer. And guess what? They come with benefits, too. When we talk about using bioidentical progesterone, like, why would I give somebody a birth control pill? And it's just like doctors are doing their best. This is what they're most familiar with. This is what doctors have been prescribing for 20 years. They didn't learn about HRT. None of us did in the 2000s. So, you know, it's just, it's what doctors are familiar with and what doctors know. But it's, yeah, I think it's a terrible treatment for parimenopause. - Yeah. - So I actually did learn about HRT in medical school in the 2000s. And I had to say that it was so wild to me when I found out that doctors and we're not getting trained in parimenopause, menopause, HRT prescribing. Like so many of the people now who are leading this big menopause movement, they've only been prescribing HRT for like three years. They just figured this out. And I remember seeing Dr. Mary Claire Haver when she said that. And I was like, you've been in practice longer than me, but I've been prescribing and managing menopausal women like longer than you and like what is happening? And I was so glad to see her bring up that topic. And for you to bring it up as well, because I think often people are like, when the doctor hates me, they don't want to help me. And what they don't realize is that their education had this huge gap in it that made it so that they don't really know how to manage things. And they don't understand progesting in birth control is not progesterone. And I had Dr. Sarah Hill in the podcast. I will link to that. We were talking all about, she studies how hormones affect women's brains. That's her research. And she's like the fact that everybody acts like progestin is this great thing. It's wild because it does not have any of the benefits that progesterone does. The best it's giving you is like keeping the uterine lining thin. You're having an IUD, but really in reality, it's just, it's not the same. And I think that's important for women to know. Let me ask you, because I've asked a few other guests this. What do you think about the fact that our whole life we've been told that birth control pills are safe? Don't question it. Don't worry about the clots. But when you get to parimenopause, and you want to use HRT, that's dangerous. Oh, yeah. You wouldn't do that. I know. It's a total double standard. It's ridiculous. It's totally crazy. I mean, birth control pills were just familiar with them, right? Like, they seem easy, but there is a lot more risks versus benefits for most women, especially as we age, especially when we're in parimenopause. And we're just not familiar with HRT. I mean, doctors are just not as familiar. So, yes, it's a total double standard. Like, why are we putting so much scrutiny on using HRT and bioidentical hormones that our body knows and knows what to do with? But then we're comfortable using synthetic estrogens and synthetic progestins. Well, and the progestins. I mean, every time a research study comes out about the breast cancer risk, those progestins are looking worse. Yeah, and worse, so on and worse. And when we consider why we believe now that we have that risk, it's the use of progestins and not progesterone when you're working with that parimenopause and menopause population. Yeah, totally. Yeah, so I want to talk to you a bit about what are the warning signs? Let's say you're in your 40s, you've entered parimenopause, your doctor is like, yes, we're managing your parimenopause, but maybe there's something thyroid going on. What are the warning signs that women should pay attention to? Well, if you start HRT and it's not working, that well for you. I mean, a lot of women start HRT and they're like, oh, I feel like myself again. And a lot of women are like, what's missing? I'm not like all those other women who feel better all of a sudden because there's a lot of other underlying issues. It's not just about estrogen. It's not just about progesterone, like softened-emout thyroid. So I mean, persistent symptoms, anything, right? Like you have persistent brain fog, you have persistent mood symptoms, you have persistent fatigue, weight gain issues, cold intolerance, just kind of feeling sluggish, you know, can be a million different things. I think thyroid is really not specific. It might even be anxiety. I mean, especially for talking about Hashimoto's, like I mentioned earlier, there is an uptick that we see through parimenopause, menopause, of women who have autoimmune disease. And as you talk about, I know that you know all this information. Women are, they don't have. They're under, women are underdiagnosed with autoimmune disease. That's a really common problem among women. And part of it, by the way, is because we're pushing, pushing, pushing all the time. Like there's a personality associated with that. So I work with women every day, and I talk to them about like, tell me about your childhood. What was that like? I mean, I don't know. 9.9 out of 10 times, she is super capable, learned how to take care of herself at a really young age. She's a high achiever now. She knows how to get things done. She's super reliable. She does all the things except there's this subtle, like, self-neglect. And it's often really subtle. And it's, you know, it's nothing to be like to have shame around. I mean, women are so used to taking care of everybody around us and especially our children. And so when we go from this transition from, you know, motherhood to like, it's called the cron phase, or I call it the queen phase, when we go through that transition, it's really, it's a really big transition. But it goes back to this autoimmune piece because there's this personality and it's so common among women who have autoimmune disease. And so autoimmune disease starts to show its face when women have these big transitions, like pregnancy and parimonipause. So there's definitely a hormonal aspect to that and of course a gut aspect too. And so that's why we've got a test for Hashimoto's. Like most women who have hypothyroidism don't know that it's actually caused by an autoimmune disease and those are two separate issues. There's the hypothyroid component, which is all about the hormones. But there's the autoimmune component, which is driving that. And so often the autoimmune component appears first. That's the first thing, but we're not testing for it. So we don't know. So it's not a hard test. Again, it's like 30 to 40 bucks. It's a thyroid peroxidase or a thyroid glibulent antibody. I like to do both. And so for women who have autoimmune disease, the signals are those signs that they would have some underlying thyroid issues. It's very complicated. Like they might be anxious and then they're depressed. And then sometimes they have like palpitations or fast heart rate. And sometimes they feel really fatigued and sluggish. And so it could be all over the map, but it's just these lingering symptoms. I mean, I think ultimately for women, if something doesn't feel right, keep advocating for yourself. Get more tests done. Don't just accept like, oh, it's aging and I'm destined for failure. Screw that. I'm so over that. Like we're getting old and we're moving into our power. Forget it. - I just have to say that we were having breakfast this weekend and your husband was like, well, I figured, oh, I'm 51 and I'm getting old. And I was like, no, what did you just say? I mean, no, I'm in a still, I'm like, I train like every day because I'm still gonna ride my bike in my 80s and like maybe I'll break a hip 'cause I'm being reckless. I don't know, but I still am like, no, I just feel like we so early start to adopt that mindset when we do that. don't feel good, but when we get pushed back on from our doctor, I do want to go back what you said about crown because if somebody's hearing about the first time, they might be like, what she just called us, Crohn's no, no. So there's maiden mother, crown. Those are the phases of our life. And somebody decided, Crohn was a bad word at one point and started to like, weaponize it against women. But it was actually like the wise woman. I think Queen is like a, you know, I think, I don't know what is that, Gen Z. That's always like, yes, Queen. But when you really step back and think about a queen, Leigh, she leads with wisdom. Like she has like, you know, this embodiment of navigating the world gracefully because she's honestly got knocked around and fallen in some holes and figured it all out. And I think it's a really beautiful perspective. What I want to talk about is what about estrogen and progesterone shifting, sometimes testosterone as well in parimonopause is increasing the risk for hypothyroidism specifically autoimmune disease. Yeah. So this is really interesting research. So this topic, we can talk about the microgendrome. This was just introduced, I think 2013 was the first time this really appeared in the research. So we're talking about sex based differences in the gut microbiome. So gender based differences in the gut microbiome, how a woman's gut microbiome and a male gut microbiome are different by design. And as a woman approaches parimonopause, she loses a lot of the diversity that she had in her younger years, which changes the gut microbiome in a really important way. The gut microbiome and hormones are very bi-directional. So gut has a really important influence on hormones and the way we metabolize hormones and like bring them in, get them out. And hormones have a really important influence on the gut. And you know, those gender based differences in the gut. And there's these downstream effects that affect the immune system. And so that's the huge part. Like gut microbiome plays a huge role in intestinal permeability, which is keeping the basically like keeps your immune system when your gut is really tight and you've got those tight junctions, we're good. And when those tight junctions become leaky, that's what people call leaky gut. And that's when we're not good. That's when we start to have more inflammation and autoimmune disease. And it can become really problematic in this like downward spiral really for women. So it's all rooted. It's rooted in gut microbiome, but gut microbiome is shaped by your hormones. Like one of the symptoms of pariamount of pause that I think, you know, most people are like hot flashes or pariamount of pause, like, but there's all of these other weird symptoms, right? Because like a burning tongue and bringing in your ears and itchy ears, like these things are like, this is weird, right? When you're living in IBS, really common, new diagnosis of IBS. And that is always I'm, I feel like I like going to run through doctor's offices, like throwing red flags when the GI docs, like, it's just IBS. Yeah, totally. Yeah. So I don't want to talk about that. But first I know that there are a while graves diseases, not common, there are people listening who are certainly going to have graves disease. So before we totally shift into the gut conversation, I feel like while we're talking about autoimmunity, let's talk about graves disease because that we can see come up as well. And it can look like hot flashes, pariamount of pause times. Yeah. Totally. Fast heart rate, so that would be hyperthyroidism. So TSH would be really low for those people listening. So a low TSH in your thyroid is like working over time. And that might feel like a hot flash that might feel like you can't sleep at night because you're all revved up because you are. Like you've got a ton of thyroid hormone. Yeah. And usually people have a pretty fast heart rate with that. And in Hashimoto's, your immune system is attacking the thyroid, destroying the thyroid. That's why we have to come in with medication to replace it, non-negotiable, by the way, I'm someone who by the time my Hashimoto's was caught, it was like, you need medication. You're not coming back from this. And I like living, I really like being alive. So very grateful to have this medication. Tell us how that's different from graves. How does graves actually work? So when women have graves disease, that's more of a stimulation. So we're stimulating the TSH receptors. And so overproducing thyroid hormone. Mm-hmm. And I think that's important for people to know because they're going to be, you know, often they're like, why do I have all this thyroid hormone? And it's because your immune system is actually making, basically making your thyroid work over time. And so these, the symptoms of graves of this hyperthyroidism is they're the same things that you can experience if you're overmedicated with thyroid hormone. Now, overmedicated with thyroid hormone over a long period of time, we're talking about cardiovascular risk. We're talking about bone risk. But what are the signs short term? So you put a patient on thyroid meds, you're like, we're going to check you in six to eight weeks. But I know you say, look out for these things in the meantime. Anxiety can sleep very well. Like kind of the insomnia piece. Feels like you drink 10 cups of coffee, racing heart, really fast heart rate. I mean, you can like just feel your pulse. It's often over 100 and women who have graves, sense of dread. Yeah. It's a sense of dread, exactly. Yeah. Yeah. And also a patient say like I'm buzzing like I just feel like there's like electricity running through me and I'm buzzing. And so if you're feeling that amped up feeling and you're like, I have hypothyroidism, well, nobody says you can't have more than one auto me on disease. But also, you know, that can sometimes be an attack on the thyroid happening with Hashimoto's or it can be that you're overmedicated. And I think that's really important to pay attention to, especially because historically there was a trend of like women who wanted to lose weight being put on thyroid medication. We should talk about that. Yeah. Because weight gain is a symptom of hypothyroidism. I mean, I remember I couldn't like workout because I was like in so much pain recovering and and I was putting on weight. So I had my son and then six months later, I didn't even fit in my third trimester of pregnancy clothes. I'm like going the opposite direction. Like first I lost a bunch of weight. Now I'm gaining a lot of weight. I think we should talk about this in the context of what is going on. And women should be aware of and then caution that we don't want to use thyroid medication for weight management alone. Yeah. I mean, I see both sides of the coin in my clinic. I see women who are under treated with thyroid medication. And then I definitely see women who are over treated. And I'm not a big fan of that. It's not good for our bone health. It's not good for our cardiovascular risk, especially as we're aging. It's not good for our mood. I mean, I've had patients who had severe anxiety. She had a 30-something patient who had such severe anxiety. She stopped working. She was living with her parents. And when I first looked at her thyroid labs, all of her T4 and T3 were way off the charts and her TSH was suppressed. And that's what we call Iatrogenic hyperthyroidism because you're on too much medication. So we started weaning off that medication and she did great. I mean, it wasn't all that complicated, honestly, to get this woman her life back. Unfortunately, it was a problem of over-medicating. So yeah, there's a sweet spot. It's like everything too much of a good thing is a bad thing. So I think that's something to be aware of and careful with. I deal levels of T4 and T3. We talked about TSH, but I'd love for you to share that with people. So I like a free T4. When I'm checking labs, I'm checking unless women are pregnant, a free T4 into free T3. So I like free T4 above one, usually like 1.1 to 1.4, something like that. And free T3, I like in the three. So 3.2 to 3.8 is usually the sweet spot. Now the tricky thing is when women are on thyroid medication, when to test. A lot of women, especially in the conventional paradigm, are given zero instructions on when to get your lab strung in terms of when you are, you know, if you're taking thyroid medication. So if I have a woman who's taking medications that include a T3, so that might be like some sort of leave out theeroxine, synthetic, tyrosin, plus the T3 would be cytomel or lyothyronine. I want her to get her labs drawn four to six hours after taking that medication so that I can see the impact of T3. And then we can titrate the dose. We might increase it. We might decrease it. It depends. There's also natural, desiccated thyroid like armor that has T3 in it. And so again, same thing. I want to see her labs four to six hours after she takes those medications. So I have some idea of the impact. Whereas if you're taking a T4 only medication, most women take that medication first thing in the morning and de-stemic as instructed and then they go get their fasting labs drawn. And of course, they're free T4s kind of high, but that's all artificial because that's from the medication. So if you're taking a medication and you really want to know your free T4, don't take it before your labs are drawn. Take it after. At the time of us speaking right now, the FDA is going to remove natural, desiccated thyroid hormone from the formulae, from being available to people. What impact do you think this is going to have? And do you think this is a wise move? No, I don't think it's a wise move. And I used to use a lot more natural desiccated thyroid in my practice than I do now. I rely a lot on Leavotharoc, well, a name brand version of Leavotharocsene and Lyotharine. You can say. Yes. Because most people are going to be like, "Leavotharocsene, what's that?" Here's how you're getting prescribed. So the generic Leavotharocsene, the name brand that I like the best is Turescent or Synthoratus is also a name brand that. Talk about why you like Turescent. Yeah, I like Turescent because there's very few exhibits. It's just a really lean medication. It's got three med-- it's got three ingredients. sleep at the aroxine glycerol and water. And it comes in a capsule and it comes in a solution. The solution's great for people of absorption issues. - So, don't you want to listen up? - Yeah, I mean, it can be more effective for, sometimes when women is on a sleep at the aroxine generic, we'll see like TSH will not be as reliable. It'll be up and down because her thyroid medication isn't as reliable. So, you know, and then we can use this synthetic T3. So here's the deal. This is an interesting one with paramanopause. When we used to use Premerin, that's not bioidentical to a woman. It's not really even bioidentical to a horse, but it would be the closest, right? Like, it's almost, like, it's more bioidentical to a horse because it's made from a horse's urine, from a pregnant mare's urine. So with armor, thyroid, it's the same thing. It's not bioidentical to our thyroid hormone. It's bioidentical to a pig. So, for most women, it has too much T3 in it. It doesn't mean I never use it. I have some patients who feel better on it and I listen to my patients so that when they're like, hey, you know, literally there's like a handful of patients who can tell me, I felt better on the armor thyroid. And so we'll go back on it. But I mean, most of my patients are on synthetic T4 and synthetic T3, which is bioidentical, by the way. So synthetic doesn't mean it's not bioidentical. The important piece is that it's bioidentical. - I think that's important that you said that I really appreciate bringing that up 'cause we talked about progestins before, which don't look like or act like progesterone at all, but synthetic, levothyroxin looks like, acts like T4, side-amel, looks like, acts like T4. I really, T3, sorry, thank you. I really, I was gonna start talking about Terson. So I was going back to T4. So Terson, I like that you brought it up for people with absorption issues because I see that people on GLP ones because their gut modility slows, they actually do better. And I will even advise people sometimes like take it at night. So you have an eaten for four hours, like you're getting in bed, take it, you don't take it with magnesium. So if you, I just want people to know, if you take supplements at night, that's not done the in-option 'cause you have to have everything away from this. But I really like that one. I see that it performs really well. And I appreciate you bringing down armor. So there's armor, NP thyroid, nature-throid is like often on, is it available? - I've been able to get it for years. - Yeah, I used to be thyroid. - I haven't seen that for five years or so. - Yeah, I used to be on nature-throid. I felt phenomenal on that. I switched to NP thyroid. There was a time where as I go, I feel awful. Low and behold, they have a recall. It happened a second time and I was like, your girl's out. I'm switching, I'm just going with, leave with a rocks in and then I just monitor things if like, do I need side-am-el? I'm pretty good about keeping up my conversion. But life happens sometimes. So sometimes I do need some T3. But I think taking away this option is a really bad idea because some people, natural-discated thyroid hormone is all that helps them. The only thing that makes them feel good. And then when the standard super-treat rate, $5 prescriptions over at right aid or whatever are not working, if we can't get natural-discated thyroid hormone, we're going to start looking at compounded. And compounded is tricky. There are very, very good compounding pharmacies out there who are very rigorous. If you are a practitioner listening, you want to meet with them, you want to ask them all the questions. But then there's lots out there that are like, you can make a lot of money with hormones. So we're just going to like, mail order all kinds of hormones that can be prescribed. And so that's where things get tricky. And we know that FDA is like, I want to shut down compounding pharmacies. But when you're dealing with a hormonal issue that is due to auto-immunity, it's not so cut and dry. It's not like, when you have somebody that has primary ovarian insufficiency and they've got 21 hydroxylase antibodies, it's not as easy as just doing your run of the mill and estradiol patch and then hitting them with progesterone because that immune system's involved and that's running a month. So I very much am like, we should not be taking away options, especially because, Synthroid makes a lot of money in the United States. And I have a big question mark, Marty, if you're listening, I have a big question mark of like, did they have influence in this in the same way? Because they often are the leading prescription in the United States, which speaks volumes and how much hypothyroidism we have. Totally. Now I agree with you. I mean, we need options. And I use compounding pharmacies for some things. Thyroid medication is not really one of them. And it's because we're dealing in micrograms. It's such a small amount. It's really hard to be precise for those prescriptions. So I don't really, I don't love compounding T4T3 medications. I'd rather have the option to prescribe armor with them women. I agree. And I think sometimes compounding pharmacies make, they'll be like, we can do it in a liquid. Thought I'm always like, we just, I just want consistency day in and day out. Your adrenal glands and your thyroid love consistency. They don't love like all over the place. Totally. So I want to ask about how, you know, actually, I was going to ask about exercise, but I want to go back because you mentioned GLP ones. I've brought it up. I had McCollum of Pearson. As you know, she's a lot of thyroid. She has a weight loss clinic. Talking about her utilizing GLP ones in thyroid patients. Is that something that you're doing as well? It is. Yeah. Same more. What do I like? Does it taste? Does it taste? The answer is yes. I do microdose GLP ones in some patients. So especially tersepotide. Tersepotide has been studied in autoimmune diseases like psoriasis. We know there's some anti-inflammatory effects, as well as weight loss effects. I think it's something to be cautious with. And it's really important that women who are on a GLP one are doing it the right way, because you can lose your muscle mass, which is your metabolic engine, gives you a lot of good things. Also protects you from things like autoimmune disease, which is pretty cool. But yes, you can do a GLP one the right way, and you can do a GLP one the wrong way. And when it's done the right way, I do see that it helps a lot with inflammation, and it can help with autoimmune disease. Let's talk about microdosing, because something that I was just made aware of is that there are some people saying 2.5 milligrams of microdosing. Oh. And I'm like, wait, what? I consider microdosing like when we are at.25. Like we are the starting dose, and we are not going up to the dose that we need to actually initiate weight loss. So we know that at that lower dose, that's where we start people, we gradually work them up so that they have less side effects. But that's not going to be a therapeutic dose for weight loss for people. So when you say, and the reason why I do.25 is because less side effects, but also it's very easy to measure in these. I know that McCall, she uses compounding pharmacies. She does things very differently. I'm always like, how do I make it so easy on the patient? Again, women are doing enough. I don't need to just make this as easy as possible. When you say microdosing, what are you talking about? Yeah. So it depends, of course, talking about true zapatite or some of the gluteides. But if we're talking about temporary, true zapatite, I usually start at.5 milligrams. And so like about a fifth of this starting pharmaceutical dose. So in the pharmaceutical world, we start at 2.5, ramp them up to 5, then 7.5, and so on. And that happens within weeks. In my clinic, we start at a fraction of the dose. And then just really slowly, tight trade up. But I tell my patients, you're kind of like, you got to chase this threshold. So it's important to keep increasing your dose because you've got to chase this threshold. And when I say threshold, I'm talking about benefits and then risks on the other side of that hill is where the risks come up. So we don't want to like cross that hill where you don't have an appetite anymore and you stop eating food and then you lose all your muscle mass. And yes, you lose weight, but you also lose muscle. The goal is fat loss, not muscle loss. And so it's really important. You have to feed the machine. You have to feed your muscle. Ultimately, if you're not eating and you're losing fat and muscle, you're slowing down your metabolism and you're telling your metabolism, like, hey, go into hibernation mode, I'm rude. I can't find any food here. Slow down. And that's like the opposite goal. What we're trying to do is feed the machine and rev the machine and get it moving. And so you got to feed yourself. And so if you go past that hump and you are to a point where you're not eating anymore, you're going to lose weight, but you're going to lose muscle too. And so the right way, the way that we do it is we increase just really slowly. And if you get up against that hill where you feel like, oh, I'm not just and you don't eat, you got to back back down. And then probably like another couple of weeks or maybe months, you'll be able to go back up to that dose because you're going to be less sensitive to it the longer you're on it. But you do have to keep increasing it or it's going to lose efficacy. And when I was saying 0.25, I should clarify that that was semiglutide. So yeah, as you said, that was like, oh, wait, I didn't say what I was specifically speaking about. You said there's a right way and a wrong way to do it. So part of that right way is let's go slow and let's not lose our appetite. So we keep eating what other mistakes are people making when they use GLP ones? I mean, not lifting weights is a big one. One of the priorities we always tell patients is like, you got to eat enough. You have to eat enough protein. You have to eat enough fiber as well. But prioritize protein and fiber, prioritize weight training because you've got to build muscle. The goal is that you've got to do it. build muscle lose fat. And so we'll have women use like an in body scan or do like a body composition scan prior so that we understand like where's your baseline and then during treatment so that we can see actual numbers. Are you losing fat and gaining muscle? Are you losing muscle? If you're losing muscle like we got to dial back, there's something going wrong there. Yeah. And how much strength training are you recommending in a week for patients to maintain their muscle mass? I mean the reality is whatever you do is is better than nothing. In an ideal world, I would love to see somebody in the gym for an hour or three to four days a week. That's what I do personally. I mean I do I lift weights four days a week for a least an hour. And when it comes to protein intake, when people are losing their appetite, how do you help them overcome that, right? Because you're talking about dialing back, but it is something that your appetite is going to come down. Like you you are going to want to eat less. You shouldn't lose your appetite altogether is what you're saying. But people are going to be like it's easier to eat carbs, right? That's less filling than eating a steak. Yeah. I think really if women are having appetite loss, you got to dial back. It shouldn't be appetite loss. It should be food noise. So they're not craving suites. There's less food noise, but you're still eating three meals a day, getting 30 grams of protein at least, especially a breakfast, but three times a day and carbs. This is where the carb conversation can be really interesting. They are GLP ones are insulin sensitizers. So they should, nutrition's nuanced as you know, everyone is going to be different. But what I see in most of my female patients, these high performing high achieving women, they're not eating enough carbs, they're eating a ton of fat. And so when you're on a GLP one, most of these women, especially I'm talking health conscious women, you know, often following like a paleo style diet, hey, been there done that. Like I was her when I started looking at my macros, I was eating so much fat. It was all good fat, almonds, all the stuff, all the healthy fats, avocados. But I had to dial back on the fats. And when you're on a GLP one, it's important to dial back the fats a little bit and increase complex carbs that have fiber. So things like oats, whole fruits, those are great. Of course, like we're not, I'm not advocating for sugar and you know, juice or whatever. But complex carbs with fiber and protein can be really helpful in this phase of life, especially if you've got a GLP one on board. And you're more sensitive now, you've turned up your insulin sensitivity. You're going to be able to tolerate this more. And of course, if they come in the right, like if they're packaged really well, like a resistant starch, that's going to be better tolerated for blood sugar as well. And how do you feel about liquid proteins? So collagen, doing protein powder, smoothies. Yeah, I personally do use a protein powder because I have a hard time getting enough protein in on my days that I work out. So I do get like three scoops after my workout. I get 30 grams of protein in that. I don't count collagen toward my protein macros, but I still use it because it's good for hair, skin, nails, gut, you know, all the things. So I still use it. I stick it in there, but it doesn't count toward my protein goals for the day. But on days when I work out, I add a 30 gram protein shake after my workout. Now, you have to be really careful about what you're choosing. And I mean, there's the flavor issue and the tolerability issue. Way protein, if you tolerate it and you can get a really good quality one, go for it. I cannot do away protein personally. So everybody's going to be a little bit different. And if you want to just get it from real food, like obviously that's the best choice. I just got to work. Right. Like I got to like come up with a decent solution. So really high quality pharmaceutical grade stuff that's been third party tested. I personally use like, I like metagenics has a protein powder I really like. So then everyone you want to look for the GMP manufacturing. Because that is going to be the pharmaceutical standard of man, man, manufacturing. I just laughing as you were like, I don't count my collagen. I'm like, neither do I. And I drink like 40 to 60 grams of collagen every day. Yeah. What I always, I'm like always adding it to my tea. Like I'm always adding it to beverages. But yeah, as you were saying, though, I was like, yeah, I don't know. Wait, we got to explain why does collagen not count? Right. You know, especially post work at it noters greatly. Yeah. So collagen is not a complete protein. It doesn't have loose scene. Losing is really important for building muscle. Yeah. I think that's important for people to understand. But again, yeah, I'm not worried about my 40 grams of collagen a day because I'm in my 40s, which I like to make jokes about how my body's like, yeah, even that collagen building thing we used to do, we're done. Yeah. We're done. Yeah. You got to keep your hair like the 40s is also this time when women really have a lot of hair loss. So I mean, it can help. It's not going to solve hair loss. But let's go there with hair loss that has you said it and women are going to be all over it. Hair loss can be hypothyroidism, but what sure? Yeah. So thyroid is like a deal breaker for hair loss. But female pattern hair loss is really common in perimenopause. And often it's a relative increase in androgens. So this is where I love the functional medicine lens because we know how five alpha reductase works because we've always been testing this on a Dutch test. Yeah. So you can see we've been testing this forever. Like you can see how a testosterone breaks down in the body by looking at this enzyme five alpha reductase. And when you turn up the dial on five alpha reductase, it'll make more androgenic metabolites. And so women who happen to have a higher five alpha reductase activity are more likely to lose hair if they take testosterone. So that can be a big problem during hormone replacement therapy, of course. And or like if you're taking a supplement like DHA for some women. And we have a relative increase in androgens to estrogens, which is really common with female pattern hair loss. And that's when women start to lose hair like the scalp starts to widen. So it's that kind of hair loss, not like patchy hair loss because there's other causes of hair loss like autoimmune issues and all that. So so yes, five alpha reductase is a big deal. Things that can down regulate or turn the dial down on five alpha reductase. I love this one because it's estridial. So estridial can turn down that dial, but it also offsets the quote of a quote. Estridial turns down the dial. Like I love that. I'm going to make that into a wrap. Estridial can turn off like can turn down that dial for five alpha reductase. And it helps with that kind of ratio between estrogen and androgens. Zinc, sapometto. Those are some other favorites that can turn that dial down and things that can turn that dial up or make it worse. It's of course testosterone or DHA, which I love DHA. I just don't love a lot of DHA. And I don't love it for everybody. Well, and it's crazy because it's over the counter to and that's something I don't know. I always go back and forth on things because in a lot of countries, a lot of things are over the counter and people are doing just fine. But in the United States, I don't know what the deal is with DHA. But like women will be like, I got this DHA on Amazon. I'm taking 50 milligrams and now my hair is falling out. I'm like, yeah, of course it is. Like that's does far too much like far too much going on. So I always caution people with using DHA even if it's topical. It's really common in women will jump into that for fertility treatments because they heard it on a forum. And yet we know that if you've got too much testosterone, you're pushing too much of that, that can be problematic for a quality. So it's not, it's one of those hormones that I'm like, it seems benign on paper. But in reality, it can be really problematic. Yeah. I mean, it's again, it's like too much of a good thing is a bad thing. And we're all so individual. And so I mean, I can do like 10, 25 milligrams of DHA, 25 milligrams, and I'll get a pimple. I have some fertility patients who come to me on 25 milligrams three times a day and I'm like, whoa, but they tolerate it fine. And then other people who have taken that much and had hair loss. Unfortunately. So yeah, I mean, I would just caution, yeah, if you're going to do DHA go low, go slow, start it on its own and watch for hair loss and come off of it if that's what happens. We were talking about exercise before we took the little hair loss tangent. Women with hypothyroidism, they don't have energy, they feel really sluggish. They have a hard time recovering from exercise. And so their idea is just do nothing because I feel so awful. But I think having you explain, what's a good entry way? Because you're not going to jump to weightlifting four times a week, you know? Totally. Of course, got to correct the thyroid. But what are some of the entry exercises that women can be doing if they have hypothyroidism? So walking is the first one. I mean, moving your body is really important. And to be clear, then anybody's telling you not to exercise, don't listen to them. You've got to exercise. You just, it's going to depend on thyroid function. And also you might a condral function if you have really poor recovery. So you listen to your body for sure. And you got to work your way up toward more movement. It's going to be like maybe the most helpful thing you could ever do is exercise. So exercise also influences thyroid hormone receptor sensitivity. It makes all your hormones work better. And it can be really hard to get started, especially if you're dealing with an autoimmune condition or hypothyroidism. That's first of all, like treat it. Don't, like I don't want anybody to be dealing with untreated hypothyroidism. Yeah. Treat it. Like there's no reason to suffer. And you got to work your way up. So start with walking. If you're walking and you're doing okay, like increase it. Maybe if you've got 10 minutes in you, then go to 15 the next week, then to 20. Maybe you added weighted vest at a certain point. And then you can start doing just light weights, right? You can do five, 10 minutes a day. Like there are some apps out there and some different programs that'll give you like a seven to ten minute weight lifting workout that you do every day. So I have a patient like this. I'm sure she's listening. I love her a lot. So she started working out really slowly. She started walking. Then she started wearing a weight invest. She's going to the gym with her husband. And she's just listening to her body. Like she's taking it low and slow. Do what you can. The goal is not to like put yourself in bed for five days. If that's what's happening, you got to dial back. But again, it's this other thing where you've got to like chase that threshold because your threshold's going to change as you build up more endurance, right? So like you're still it's like you don't want to go over the hill to the point where you're like, Oh crap, now I'm in bed for five days. And I feel like I have the flu and all my muscles hurt. And I feel terrible. Like if that's happening, you're going too hard. But you still got to do something and you got to like start climbing the hill. So yeah, I mean, it's just it's everybody's got a different threshold. Energy should be better when you work out. Not worse. Yeah. Well, I appreciate you saying to that user recovery is a gauge as well because, you know, often that's something that I'll say if you're struggling with adrenal and you're struggling with thyroid issues and or either or you if you are sore five days later, you did too much. You're not bad. That's just data like and yay for like in a month when you're going to be like, Oh, actually, I wasn't I'm not sore for five days anymore. But we have to individualize this. There's so much on the internet that is super prescriptive for strangers. Let that blow with my mind. I mean, especially even in the cycle thinking world with like how you have to program everything like perfect to your cycle. And I'm like, that's not true for a lot of women. Like there's a lot of women. I mean, as someone with endometriosis and also has a neurodivergent brain, when I'm coming up on my period and I'm on my period, if I want it not to suck and not to be painful and I don't want to be depressed, like I have to go heavy. I have to lift heavy. That's what works for me. And that I bring that up because I think people are getting disempowered by all this information we've access to that they're forgetting that their body and how they fill and their own intuition is their best gauge. Yeah, totally. I mean, listen to her. Like listen to your body tune in. This goes back to women pushing through, right? Women push through. We tend to disconnect from our body. There is a coping mechanism that happens there. We disconnect. We dissociate. And it's just this like mild thing that we get used to because we're like multitasking like a queen, right? We're doing everything except for really connecting with our bodies. And so I think what's important is like really get in there, connect with your body, focus on like being in body, be in your body, get in touch with her. What does she need? How does she feel? Take your clues. Like that's your best data is how do you feel? Absolutely. But most women are not connected with their bodies. Yeah, I love that you say that. And you know, for people listening, I think you sometimes when we start talking about like just go for a walk, there's people with like pots, there's people with hypermobility issues. I always am like if you have something special with exercise, occupational therapy or physical therapy, that's going to be your best. But even when you sit at a desk or you're somebody who is stationary, you can be doing arm exercises. Like you can be doing yoga stretches. Like, and I think it's just important to also understand that like there is a way for everyone to find exercise to find movement. Even when individuals like, you know, they need to have somebody moving their body for them, but still getting that movement in place. What I want to ask you is what exercise mistakes do women with hypothyroidism often make that completely backfire on their energy and metabolism? I mean, doing massive cardio, running marathons. I also have a patient who's doing that right now. She's training for a marathon in her 40s. She's got parimenopause thyroid issues. She's had a big wall. Yeah. It's just too much, you know, there's so there's only so much that our bodies can handle. I'm not saying women should not run or challenge themselves or be like be a, I'm an athlete, like be an athlete. Do the thing. And you got to understand like what your body is capable of and how much resilience you have. So if there's underlying health issues that compromised your resilience, it's probably not, you know, doing a marathon is probably not the right thing. It might be eventually like maybe you work your way up to that, but if you're getting symptoms and you're like hitting a wall, like that's a good time to maybe change your goals for the year and focus on your health. So anyways, I think the biggest one is probably neglecting the strength training piece and overdoing the cardio piece. Some cardio is important, right? It's good for our health. Like I, for my patients who have a lot of resilience, we'll do like sprint interval kind of training. You know, hit training, like great. Like we can add it in. And if you have a lot of stress in your life and you're trying to like work and take care of aging parents and take care of your kids and you know, manage your household and do all the things like it might be too much for a lot of women. Totally. I think that's really important to just emphasize that if your exercise becomes a chronic stressor in a negative way, that's going to have a negative impact on your hormones. And I have to say my 20s, I always thought like, when do I want to run a marathon? And then I volunteer a few years at the Portland Marathon Medic booth. So I'm at the finish line. And the people who finish marathons, I did not want to be those people. There's some amazing people, but I mean, I remember the guy with the best time ran straight into the tent and was like, please get me an IV and collapsed. And I was like, so you had good time, but is there a worth it? I mean, for him, he was like, yes, I am. I'm like, the best marathoner in the world. Yeah. And I was like, oh my gosh, this is like so hard on the body. And so I don't think like that means marathons are out. But I do think that you should always about, it's just the same like cold plunging rain when all of these things that are stressors and they're great stressors, fasting, great stress are in the right context. But in the wrong context, you've just sabotaged your energy, your metabolism. I can't even tell you how many female bodybuilders, also marathon runners, who started gaining weight, couldn't control it. And it's their body was basically fighting back of like, no, not doing this anymore. And sometimes that feels like your body's betraying you, but it really is a wisdom of like, we need you to survive. Like, we're in this together. Yeah. I do want to switch gears to got health now. So everybody promised we were going to go there. You had mentioned how hormone health influences the got microbiome. Can you say more about especially hormone optimization in perimenopause, menopause, how is not affecting the got microbiome? Yeah. It's so it's such a really fascinating area of research that is merging in the last decade, really five years even. So the got microbiome is influenced by hormones in a really big way. Guess what? Estardial influences and intestinal permeability. So those tight junctions we talked about earlier are positively influenced by estradiol. Guess what? Negative interest influences the got microbiome birth control bills. So there's another like, why are we doing this? So estradiol can influence the intestinal permeability in an important way. It also shapes the composition of the got microbiome. Some emerging research suggests that HRT positively influences the got microbiome composition, which is a big deal for lots of different reasons. The got microbiome also will influence things like histamine. So when we have all these different crazy symptoms that appear in perimenopause, like itchy ears and itchy skin, like there's a reason for it. We can go look at the got microbiome because estradiol is going to impact the way that histamine works in our body and of course, progesterone is playing a really big role in stabilizing mass cells, which release histamine. So there's a huge component there. We also see women who go through perimenopause tend to have more hydrogen sulfides. So that's one of the types of SIBO or small intestine bacterial overgrowth. And hydrogen sulfide can be really toxic to the cells and our colon. So those are kind of three big ways that that estrogen and progesterone in particular play a role. Sorry, I'm just like, because you're like hydrogen sulfides really toxic to our colon. I was like, and to our partners and and to everybody else in the household. So those are like rotten eggs. There's studies that are like women because of women's diverse microbiome composition, we tend to have stinkier gas. But that is definitely one that when you smell like rotten eggs, like, yes, it's not just, so I'm said, this you can tell I have boys, my children are boys because I'm like fart joke immediately. I've got one too, girl. I go until. So I think this is a really important point of weight. You and I were talking about you had said something to me like, Oh, I saw that like you like oats. And I'm like, yes. And we were talking about how male influencers are out there telling women no one should eat oats. And our conversation was I had said to you, but I have a diverse microbiome and you don't buddy. You do not. So I have to have as much diversity as possible to keep up with that for women who have been influenced to be afraid of grains and carbohydrates. What do you want to tell them about their gut microbiome? Because this is crucial going into menopause. Yeah. I mean diversity in the foods you eat is critical to maintaining diversity in your gut, specifically fibers. And we're going to get fibers mostly from carbohydrates. hydrates. I mean, whole fruits, okay? Like we're talking whole fruits, not fruit juice. We're talking whole oats, not oat milk. So there's good carbs and bad carbs, just like there's good fats and bad fats, right? Like stick with the good, complex carbs that have fiber. Those are really important for you. Got microbiome, get diversity, try new foods. Like eat probiotic rich foods. Of course, this is my backfire and you know, if you have histamine issues, but like it's complicated, but you want to eat diversity, right? You want to support the diversity of your gut microbiome. And as your hormones are declining in paramanopause, that's especially important. Plus that hormonal impact on your gut microbiome plays a big role. And so if you are candidate for estrogen, that might help your gut. I can't like have one other patient who has inflammatory bowel disease. She flared during paramanopause. Like she was really, she's like a nutritionist. She's super dialed in what she eats and her lifestyle, low-tox living, all the things. And when she went through paramanopause, she just flared. And so the things that made her feel a lot better was HRT, like was a game changer for her actually. And then we added in a postbiotic supplement, which was like the bow on top. And you know, now she can, she has a lot more tolerance for foods and she's not flaring. So yeah, all that stuff plays a big role. Yeah. And as we're talking about, you know, inflammatory bowel disease, Crohn's disease is actually, I want everyone to know this because I think it's so important. Women who take oral contraceptive pills, the birth control pill, the pill, their high risk for developing Crohn's disease. So new onset. So we know hormonal shifts can trigger autoimmune disease. Birth control pill is implicated in that. It also can decrease microbial diversity and leads a leaky guy as you send. And we see women who do have Crohn's disease. So they already have it when they take the pill, they have more frequency of surgical intervention. So I just want to bring this up because if this is you and you're in paramanopause, the pill is not for you. And you can tell your doctor to take a trip to PubMed because there's enough research there to justify why they can do better with an estradiol patch and an oral mechanized progesterone or even a vaginal progesterone. But with the microbial diversity, what happens when we lose estrogen? Because this I think is you may say what I read in a paper, but this I think was so shocking to me when I read it. So yeah, age 40, we're seeing a decline in microbial diversity for women and that correlates with paramanopause, of course. So as we hit menopause, our gut microbiome changes a lot. And what like it's that's more inflammatory for a woman actually because there's other papers now looking to it. Like what happens when you when a female has the gut microbiome of a male, there's more inflammation and more immune uh, reactivity that goes on. Yeah, no, that's exact when I read that. It was like it's like a man. I was like, don't don't don't like that. We definitely want to avoid that. We have the hypothesis of why we have so much microbial diversity is because we just state the future of the human race and we pass on that microbial diversity as well and it has a big influence on their immune health. And when we lose as you were saying that microbial diversity, we don't see autoimmune disease get better. So people are often like, well, then don't get autoimmune disease as much. So maybe that's a good thing. It's a bad thing. And so what can we do to prevent that? I mean HRT is one way, specifically, there's a lot of difference, right? Like a different ways that we support our gut microbiome or take the negatives off our gut microbiome like avoiding toxins or an environment that can affect our gut microbiome, pesticides affect our gut microbiome, um, antibiotic use. This is another like we see this uptick an antibiotic use in women in paramedic paws or menopause because they get more UTIs. The same women who were taking birth control pills and got UTIs when they were taking birth control pills, they can get also get UTIs when they go through paramedic paws. It's just, um, GSM genital urinary syndrome of menopause or I say it's genital urinary syndrome of birth control pills. Um, it's the same mechanism when we have low estrogen. Um, so we tend to see, you know, more antibiotic use around just like the increase in UTIs. Well, I was going to say, I just wanted to dovetail on the antibiotic use that I very much think that there's going to be research in the future that shows us that the prescribing of antibiotics over topical vaginal estridial has led to the antibiotic resistance that we see for UTI specific organisms because of this fear around estrogen because we know if we give topical estridial pliet to the vulva, that is not only going to influence the microbiome in a positive way, but also it's going to help with your urinary tract system and the pelvic floor as well. And so it's doing all of these beautiful things. And so it's something that um, Dr. Amy Killin, she was, uh, I will uh, link to her episode, but she was saying how when she was an ER doctor, like if she could go back, she would have given every woman vaginal estridial over those antibiotics because we've got huge antibiotic resistance going on. And a lot of times people are like, it's just a UTI friend. A UTI becomes pile of nephritis. We need our kidneys. You got two of them, but it's not worth gambling with even a single one. They're super, super important. So you've talked about microbial diversity built by varying what you eat in your diet. You said um, estridial, but not birth control. So I'm sure there's women right now being like, but wait, if I wanted to affect my gut, don't I have to take oral estrogen? No. The answer is no. In fact, I'd prefer that you take transdermal estridial. The oral estrogen goes through first-past metabolism in the liver and breaks down to different components that are there's there's some controversy out there with exactly what I mean, some people do believe that it can help more with heart health, though it increases your risk of blood clot. I tend to steer clear from most oral estrogens, especially birth control pill, but that's they're different, right? Like that's a oral synthetic estrogen. You can still do an oral synthetic bioidentical estridial, which is not the worst thing in the world. I mean, at all, like I still find great, but we have transdermal estrogen and I personally, that's what I use in my practice. Mm hmm. Yeah. And what we see is, is that you don't have to actually, if the estrogen is going to systemic, you don't have to take it orally for it to affect the gut. And I think that when we think of that way, it's like kind of the way medicine has taught us to think, right? Your gut is separate from your vagina, except your gut is the reservoir for lactobacillus that inhabit your vagina, but we think about like these are completely separate entities. The brain is completely separate from the gut, right? And we've now learned like that is absolutely not true. We've been talking about thyroid and we've been talking about Hashimoto's when we lose that microbial diversity, what incap impact can that have on thyroid health? Well, for talking about Hashimoto specifically, it plays a really important role with the autoimmune disease piece when you have less microbial diversity. You're more at risk of dysbiosis. I mean, that basically is dysbiosis where you have overgrowth of bad bacteria. You can also have overgrowth of things like yeast and candida, potentially like parasites or H. Pylori or other kinds of infections that increase your intestinal permeability, which is directly linked to other autoimmune component Hashimoto's. There is also this interplay of thyroid conversion. So when you go from T4 to T3, your gut bacteria plays a really important role in that in that conversion. And so having less diversity is going to impact that having more gut infections is going to impact that and potentially increase things like reverse T3. So you have less free T3. And this would be a very good argument for everyone listening to bring to your doctor of why leave with iroxin is not enough because there's a lot of doctors out there that are like, there's just you just need to leave with iroxin. Why would you need anything else? But also that you need to be checking more than just a TSH because as we get old or as we get older, nothing works as well. And I hate that. But as the reality and that includes the conversion of T4 to T3, do you find that women who enter their mental pausal years are doing better with some T3 added in? Not necessarily. I think it really depends. I test all my women, you know, all my patients, I test their T3 and some need it, some don't. I mean, there are definitely some who don't. And I would say my younger patients are less likely to need it. But it depends. I mean, I have some patients who are in menopause who don't need T3. And I have patients who have worked with me long enough where it's like, yeah, you don't need T3 anymore. You know, that kind of thing can change. As we change the gut microbiome, it's going to influence that. It also is going to influence things like nutrient absorption, which plays a really important role with thyroid function. I mean, like, you need iron and zinc and selenium and B vitamins and all these iodine. You need all these nutrients for your thyroid to work well. I feel like iodine is always the one that like, only gets attention. And you're like, you listed everything and you're like, oh, and iodine. And they're so thin. I feel like that same way that I'm always like, I need to tell you about all these others because I know you are here thinking iodine. They're women who are definitely listening right now. And they're like, okay, game over for me to lay it like I am already 10 years postmenopause. My got microbiome just gone. Like, what can I do? Yeah, no way. I mean, I would say don't ever give up on yourself, please. Like really? Games never over. Yeah. If you're postmenopausal, 10 years after menopause, I mean, you can still start HRT. I don't there's controversy around that, right? Like, the later you are, the less benefits you have. So it is better for you to start earlier. But if, you know, women's health initiative 10 years ago, you didn't have this information and you're 65, 75, whatever. Like it's it's not necessarily too late for you. To start HRT specifically, if that's right for you, probiotics, pre-biotics, post-biotics. So pre-biotics are certain types of fiber to feed the gut microbiome. I am a really big fan of resistant starch, so like cooked and cooled potatoes, overnight oats are like my go-to every morning. Pre-batic foods and eating a diet rich in plant-based fibers is important to support the gut microbiome. And then there's probiotics. So you can take probiotic supplements. I personally take probiotic supplements. I give them for a lot of my patients, but the quality really varies. And that's one of those supplements that I'm very picky about. Like there's some supplements like vitamin C, you can be less picky about. Probiotics, I'm pretty picky about. So I like spore-form probiotics and it depends on the patients. Like a lot of patients don't do great with like lactobacillus and bifidobacter, which are more traditional stuff that you find at your supermarket. And if you are one of the women who has SIBO, which is really common by the way, the small intestine bacterial overgrowth that we've mentioned, and you take those probiotics, they usually make women feel worse. And so it's picking the right probiotic for, you know, and postbiotics. Postbiotics are really this new kind of emerging area of research I've been using. It's a supplement that's over the counter. Actually you have to have a physician's link to get it, but it can be really helpful for some of our patients. Like just like I say it's like putting the bow on top when you use that, like the postbiotic can be really helpful. But I think also like if you're having issues with your gut microbiome, remove and replace, like remove the infection, that's the big deal. What I see most people do is they remove foods and then they're on these really restrictive diets and they're auto-mune paleo and they're diversity's even lower because they're and they're scared of food and their stress is even higher because it can't eat anything and they can't like go out to dinner with their spouse or partner or friends or whatever. So yes, there are certain foods to remove. Alcohol is a really important one to get rid of or at least limit a lot. - If you want to get rid of hot flashes, dropping alcohol is like the first thing you can do. - Alcohol is not doing us any favors. Let's just be really clear about that. If you want to have a drink, have a drink, but don't do it under the impression that is doing any good stuff for your health. - That's actually a good point. I appreciate you saying that because the same people who were influenced by the Women's Health Initiative, it's like the same channel. We're influenced by the Get Your Resvera Troll. We love Resvera Troll. Resvera Trolls. I mean, I have a supplement with Resvera Troll 'cause it's so good for women, but it's an NA happening in wine. - You're not getting what you need in wine. And in fact, like the polyphenols, part of their benefit is what they give your microbiome, which is some serious love and alcohol is like completely the opposite. - Like stay off the alcohol, drink some green tea and eat a pomegranate. I mean, and again, like if you wanna have a drink, have a drink, but don't do it because you think it's benefiting your health or good for your heart, like that's crap. So anyways, where is it going with this? So if you are whatever age, I think the important piece is to realize, like yes, there are some things to remove, but the important thing to remove that is getting ignored all the time is the infection. There's usually some underlying gut infection of people who have digestive issues and food sensitivities and autoimmune disease, and the most common one I see is SIBO, bacterial overgrowth, but there's also SIFO, so fungal overgrowth or other sorts of overgrowth of yeast like candida. There can be other types of fungus overgrowth. Like sometimes I see women who have really high aspergillous levels, especially if they lived in a moldy house. Like that can be a big, huge one. - Moles the worst. - Moles the worst. - Age, pylori, like there's other sorts of gut infections and infections impact your intestinal permeability in a big way. So yes, you have to rebuild your gut microbiome, but first don't forget to remove the infection and then replace the enzymes. Sometimes replacing digestive enzymes is really important and especially for women who are 65, 75. There's a really common issue among older people and it's exocrine pancreatic insufficiency when women don't make a lot enough elastase from the pancreas. So one of the main risk factors for that is just age. So as we get older, we make less pancreatic enzyme. And so sometimes it's really helpful to replace that. Sometimes it's really helpful to replace stomach acid so we can use butane HCl. That's another one where it's like meh, you might want to do it with a practitioner or just be cautious, start low, go slow, listen to what happens. There's a lot of different digestive enzymes we can add in for women who like gallbladder function is a huge one. How many people don't have well functioning gallbladder or have had their gallbladder removed? That's when I tend to add oxbile or other nutrients to support gallbladder function. Bitter kind of compounds can support gallbladder function. And this is back to that carbohydrate fat conversation. I've had a lot of women who have had better digestive function when they, I'm not going low fat here. Just let me be clear. Like I'm not low fat, I'm not low fat trained, but removing some of the high fat foods, high fat can actually increase in test on permeability and it's really hard on the gallbladder. Your gallbladder has to work extra hard to squirt out bile every time you eat like a really high fat meal. And so pulling back on some fat, adding in complex carbs and fiber, of course, prioritizing your lean proteins, all that super important. But remove the infection, remove some of those like big, offending foods, like I don't even set it. I think I said gluten, but gluten for a lot of people who have digestive issues and alcohol are kind of the big ones. Refined sugar, maybe some dairy for certain people. So I sometimes write some of the big stuff, but I don't love really restricted diets and then replace digestive enzymes. And then later on, you can really focus on like, okay, now can we bring in some more like, probiotic foods, maybe you'll better tolerate things that are high histamine like sourcrout and kimchi after you've really fixed that balance and maybe addressed the hormones and brought in some more progesterone. The thing is, it really is like this very complicated puzzle. And I'm, you know, I just, I tend to just like see all these like connections. I've always had a hard time. I can't focus on gut health because the hormones are important. I can't just talk about hormones because the gut health is important. And then you gotta bring in the thyroid piece. So it really all goes together. It's a big puzzle. - Yeah. And to your point about restricted diets, you know, I'm actually, so I'm friends with Mickey Trascott who really, I think she might be the only autoimmune paleo author of making cookbooks. And so I know her personally in real life and people will always say like, oh, she wants you to like lead this really restricted diet. I'm like, no, she had to do autoimmune paleo. It was really overwhelming to her. So you made all these cookbooks and she's coming out with another one, which I think is really great because it addresses how people took it too far. And that's, I think exactly what happens, especially in paramedic mods, anytime you have intestinal permeability, hyper permeability happening, that happens in paramedic mods, people just start taking out foods. They need a guide. They need someone to work with. Then I also see a lot of online influencers who are like, this is the AIP way of life. And like you have to eat like this for life. Or here's low fadmaps for life and low histamine for life. And I'm like, I would never do this for life for myself because I love to eat. And I come from a culture where eating is community. Like that is how you stay in community, which is more honestly, community is probably better for our health than necessarily some of these foods that we're eating. And so while these, I want everyone to listening, you might be on this diet and it might have a time in a place, but it should not be forever. Like the ideal is your gut should be, it is designed, but it should be able to eat a big robust variety of foods. And if you can't do that, there's something else going on. You brought up giving bile acid. We know that bile acid's toxic to those organisms that should be in the large intestine, but they get their way into the small intestine. And so if you're somebody with gallbladder disease, which we know in your 40s, right, fair skin, you're still fertile like that estrogen. So there's this whole, people are like, what are you talking about? There's a whole acronym. Well, isn't an acronym. I don't think that's what it is exactly, but there's, I'm like, we all remember it. Like the three F's, we don't know what it's called. Well, it's a fourth F, right? But it's not politically correct to say like, fat, but that is the one that as clinicians, we memorize these things because if you are overweight, if you are still cycling, you are in your 40s and it tends to be women who are white, are risk for gallbladder disease. And automatically, I mean, Dr. Drew, you're always so happy to get rid of your gallbladder. I call it like your designer purse of your liver. Like it's like your accessory, your liver loves it. Like would you throw out like your designer purse? I don't know a designer purse name right now, but would you throw that away? No, you wouldn't just throw that away. But when you were talking about SIBO and SIFO, that's what was coming up for me is that. So often people don't check for that. Why is it so common that we are seeing these microbes ending up in the small intestine and calling that their home? Well, I think that's the big question. I mean, there's a lot of different reasons. I think stress is one reason. So I practice meditation. One of the goals of meditation is called coherence. Coherence is organization of the heart and mind and the brain. So we're doing studies now to look at coherence of the heart and mind and then coherence of the stomach. So it affects your peristalsis, stress and survival mode, affects your digestion, right? So it's, we know this because we talk about the parasympathetic and the sympathetic nervous systems. These are ranges of our autonomic nervous system. Sympathetic dominance is fight or flight. Parasympathetic is rest and digest. If we're in parasympathetic all the time, great, but we're not. That's just not our culture. So many women live in the sympathetic dominant state. So many people, men and women live in the sympathetic dominant state. We're not putting a lot of energy into our digestion, first of all, but also just that coherence. So coherence refers to organization when it's disorganized. We tend to be more at risk for SIBO and other gut infections, but especially SIBO. SIBO is the one I'm really interested in because I see it all the time. It's so common. And for a long time, I thought, well, maybe it's just a downstream effect of other issues. But now I think it's just so common because of our lifestyle and because we live in such a stressed out stress and survival mode, right? So I think that's a piece of it with SIBO. Also, if you've had your gallbladder removed and you're not squirting out bile every time you eat, you're not killing some of those organisms. Also, if you have low stomach acid, which goes hand in hand with being stressed out, actually. So low stomach acid is going to make you more at risk for infections. You want to have stomach acid for a reason. God gave us stomach acid for a reason. So there's a lot of people out there on acid blocking medications. Those can increase your risk of SIBO at bacterial overgrowth because it doesn't kill off some of those organisms in your gut. People have infections in their mouth, especially like root canals. That can seed your gut. And so you're swallowing that spit all the time when you have a root canal in your mouth, you're going to have usually dysbiosis in your mouth. And that's a two-way street. I mean, it's a highway between your gut and your mouth. I mean, thyroid has a huge impact on your risk for SIBO because we know thyroid impacts motility. Often we think people with hypothyroidism have constipation and that can sometimes be true. But I see the greater truth is that people with hypothyroidism have problems with organized parastalsis and are at higher risk for things like SIBO because their gut motility isn't working as it is. I mean, basically, we should eat three meals a day. The migrating motor complex and the small intestine should come sweep the streets of the intestine and clear it out. And that's just not happening for a lot of people. And part of it's because we're eating six meals a day, maybe. So that's what I work with with my patients is like, let's try to aim toward three meals a day. You don't need to starve if you're hungry. Eat. But like, work toward three big meals a day where you're eating enough at the meal and then you've got enough rest between your next meal, like four to five hours at least. And your gut has time to rest and sweep the streets of the intestine. Yeah. And another big one we see is food poisoning. Oh, for sure. Yeah. Thanks for mentioning that. Yeah. So yeah, that's a whole thing. So migrating motor complex can take a huge hit from food poisoning. I think there is definitely some autoimmune component going on with SIBO. So we can do this test called IBS Smart, Measure Antivin, Vinculin antibodies and anti-CDTB antibodies. I mean, we're looking at antibodies here. Of course, there's some autoimmune component, right? And sometimes I use LOSOS Naltrexone in patients because it supports gut motility. And I'm like, well, that's why, right? There's got to be some autoimmune component. I don't have the research to support that. But I've got the clinical experience to support that like I know LOSOS Naltrexone is going to be useful in those patients who have antibodies and have post, it's called post-infectious SIBO. So yeah, that's a huge one, which I wish I had Zyfaxon right now. Yeah. So that's a way for people listening. That's probably the best treatment for SIBO. I will say that there are herbals that do work and I have used them clinically. But when someone's really struggling with SIBO, I'm like, let's just get it gone. And it's not an antibiotic. It's anti-supdic. So it's not knocking down your microbiome in the same way that like penicillin would be. But you mentioned LOSOS Naltrexone or LDN. Are you using this in Hashimoto's patients? Oh yeah, totally. I use it all the time. You know, I try to like pick some things where I'm like, we're going to hit two birds with one stone. And so with LOSOS Naltrexone, it can help upregulate T-Rig cells, T-regulatory cells in the immune system. So it supports the immune system and decreases inflammation. And it might also improve things like gut motility. And I have patients who have like, you know, pain. They have joint pain and things like that. And I've had patients get off celibrex or motrin because their pain is gone. So it can help with pain. It can also help with appetite for some people who struggle with that. Yeah. I think and for people listening because you're going to go Google this and then you're going to be like, wait, this is a drug for drug addicts. Like when we're using LOSNaltrexone, it's, you know, one to sometimes 4.5 milligrams. It really depends. It's at that low dose that you get the benefits for the immune system. That's the one thing people should know about starting it though. Well, it can cause some really vivid dreams. Really vivid dreams. So some people who are really sensitive, I'll titrate up the dose. I used to always do this. So I start with like 1.5 and then go to 3 and then 4.5. I actually prefer now in most patients who can tell me they'll know usually if they're really sensitive or not. But I prefer to start with the full dose because patients can tell me overnight. They'll be like, yes, it helped. I have another patient who had an autoimmune condition in her eye. And she was like the next day I woke up and my eye felt less blurry. I could see better. I had, you know, so I want to know if it's working or not. That's an important piece of feedback for patients. And so I would say 30, 40% of patients can tell me like, yeah, it really helped. Yeah. I started it 3 milligrams because I was like, I want this to work fast. I know you didn't do well. Oh no. It was the worst like nightmare. It's super vivid. It was like bad things happening to my children, which is like, the worst. Yeah, I did not sleep like that whole night. And I was like, well, now we know. Yeah. I am. Yeah. I shouldn't know and better. Honestly, I'm like always so sensitive to medications that I'm like, I probably should have known better. But yeah, whenever people will tell me like, oh, I tried it, but it was so I couldn't sleep. And so I just stopped and like, yeah, okay. So your doctor needed to actually tie you off. Yeah. And like, and that was like, years of me having patients like that. And then me being like, no, I think I'll probably be fine. And I was not in fact fine. Yeah. Yeah. I mean, it's one of those warnings always like number one, are you sensitive or are you do tend to tolerate stuff? I personally like, I'm not that sensitive. So I am fine on 4.5. It's never been an issue with me. But yeah, there's definitely a handful of patients who need to go really low, really slow. Yeah. Yes. Well, I want to thank you so much for this conversation. I feel like we covered so much. And there's so many great nuggets and pearls to help people imparting. Is there anything you'd like to share with women who are in the paramanopods transition right now? I think the big one is don't give up on yourself. None of it is just getting older. Like, this is where you're just beginning. And I hope women feel maybe even inspired that you don't have to settle on fatigue and weight gain like screw that. No way. You can be the best, most beautiful, strongest, most wise version of yourself after 40, 50, whatever it is, 60 harness all the wisdom you've had. Take care of yourself. Maybe it's time to prioritize yourself. I think that's the biggest transition of mindset, maybe where women are going through this mindset change and starting to really hopefully understand that they are deserving of love and care in the same ways they've been taking care of everybody else. That's so well said. Well, thank you so much. My pleasure. Thanks for having me.